Endovascular Treatment of Isolated Dissection of Superior Mesenteric Artery.

Isolated spontaneous dissection of the superior mesenteric artery is extremely rare. In December 2012, a 45-year-old man, without significant comorbidities, presented at the emergency room of another hospital with abdominal pain. The patient was treated with medical therapy and discharged on resolution of the pain. Three months later he returned to the emergency room with a new onset of pain. CT-angiography (CTA) showed an isolated SMA dissection associated with aneurysmal dilatation. The patient was referred to our attention. We attempted endovascular exclusion of the dissecting aneurysm in May 2013. We deployed a self-expandable nitinol stent (BostonSC Adapt 4-9×32 mm) in order to simultaneously repair the dissection, preserve the branches and exclude the aneurysm. Postoperative course was uneventful and the patient was discharged on postoperative day 2. At 10-month follow-up CTA showed excellent positioning of the stent, patency of the visceral branches and shrinkage of the aneurysm.

Optical coherence tomography after carotid stenting: rate of stent malapposition, plaque prolapse and fibrous cap rupture according to stent design.

OBJECTIVES: This study aims to evaluate the rate of stent malapposition, plaque prolapse and fibrous cap rupture detected by optical coherence tomography (OCT) imaging according to carotid stent design. DESIGN: It was a prospective single-centre study. MATERIALS AND METHODS: Forty consecutive patients undergoing protected carotid artery stenting (CAS) and high-definition OCT image acquisition were enrolled in the study. OCT frames were analysed off-line, in a dedicated core laboratory by two independent physicians. Cross-sectional OCT images within the stented segment of the internal carotid artery were evaluated at 1-mm intervals for the presence of strut malapposition, plaque prolapse and fibrous cap rupture according to stent design. RESULTS: Closed-cell design stents (CC) were used in 17 patients (42.5%), open-cell design stents (OC) in 13 (32.5%) and hybrid design stents (Hyb) in 10 (25%). No procedural or post-procedural neurological complications occurred (stroke/death 0% at 30 days). On OCT analysis the frequencies of malapposed struts were higher with CC compared to OC and Hyb (34.5% vs 15% and 16.3%, respectively; p < 0.01). Plaque prolapse was more frequent with OC vs CC (68.6% vs 23.3%; p < 0.01) and vs Hyb stents (30.8%; p < 0.01). Significant differences were also noted in the rates of fibrous cap rupture between CC and OC (24.2% vs 43.8%; p < 0.01), and between CC and Hyb (24.2% vs 39.6%; p < 0.01), but not between OC and Hyb stents (p = 0.4). CONCLUSION: Intravascular OCT after CAS revealed that micro-defects after stent deployment are frequent and are related to the design of implanted stents. Stent malapposition is more frequent with CC stents, while plaque prolapse is more common with OC stents. It remains, however, unknown whether these figures now detected with OCT are of any clinical and prognostic significance.

The wonders of a newly available post-analysis CT software in the hands of vascular surgeons.

INTRODUCTION: Endovascular treatment of abdominal aortic aneurysms has become a widespread and accepted practice in most Vascular Surgery centres. The optimal method to identify and characterise complications still awaits assessment. CASE REPORT: An 83-year-old woman was admitted to our Institution for volumetric expansion of the aneurysm sac due to a suspected type II endoleak. Post-analysis, using OsiriX, revealed the presence of a hole at the distal portion of the main body in the docking zone near the flow divider. CONCLUSION: OsiriX is an image processing software and an attractive alternative to dedicated workstations and allows rendering and analysis of numerous medical imaging modalities.

Surveillance imaging modality does not affect detection rate of asymptomatic secondary interventions following EVAR.

OBJECTIVES: Literature reports that surveillance imaging following endovascular aortic aneurysm repair (EVAR) gives rise to asymptomatic secondary interventions (SI) in 1.4-9% of cases. This retrospective study aimed to evaluate whether the modality of surveillance imaging influences the detection rate of asymptomatic SI. MATERIALS AND METHODS: Two EVAR surveillance protocols were compared at the same vascular centre. Protocol I, performed from January 2003 to December 2006, consisted of colour duplex ultrasound scan (CDU) plus CT angiography (CTA) 1 month after procedure and every 6 months thereafter. Protocol II, performed from January 2007 to June 2010, consisted of CDU plus CTA 1 month after operation and CDU plus plain abdominal films (XR) every 6 months thereafter. In the second protocol, CTA was carried out only during follow-up in specific conditions. The term 'asymptomatic SI' was used when the necessity for SI was detected by imaging alone on an elective basis, prior to development of any symptoms. RESULTS: Enrolment included 376 and 341 consecutive patients with a mean follow-up of 1148 days (range 1-3204 days) and 942 days (range1-1512 days) in Protocols I and II, respectively (p < 0.001). Freedom rates from aneurysmal rupture, freedom from SI and detection rate for asymptomatic SI at 3 years were 98.3% and 98.7% (p = 0.456), 82% and 83.5%(p = 0.876) and 8.8% (n = 33/376) and 8.5%(n = 25/341) (p = 0.49) in Protocols I and II, respectively. Estimated comparison of the costs, radiation exposure and contrast used at 3 years in Protocol I versus Protocol II showed that Protocol II allowed for a three-, four- and six fold reduction in overall costs, radiation exposure and contrast used, respectively (p < 0.0001). CONCLUSIONS: The detection rate of asymptomatic SI following EVAR is not affected by the type of surveillance imaging. A surveillance schedule based primarily on CDU and XR appears to be justified.

Benefit of revascularisation to critical limb ischaemia patients evaluated by a patient-oriented scoring system.

OBJECTIVES: The concept of patency and limb salvage are physician-oriented endpoints in critical limb ischaemia (CLI). These endpoints have failed to enhance function after revascularisation. The aim of this study was to create a scoring system to predict 1-year functional status and to assess the benefit to patients possible by revascularisation. MATERIALS AND METHODS: During the period 2007-2009, 480 consecutive patients (mean age ± SD, 83.2 ± 8.7 years) underwent repair for CLI. Preoperative, operative and functional status characteristics and post-operative outcomes were recorded. The following patient-oriented outcomes were investigated pre- and postoperatively: basic and instrumental activities of daily living (BADL and IADL) and ambulatory and living status. Statistical analysis was performed to assess predictors of functional benefit from revascularisation. The variables significant on multivariable analysis were used to generate a scoring system to pre and postoperatively grade individual patient risk of losing baseline functional status at 1 year (CLI functional score). RESULTS: Ninety-three of 480 patients (19.3%) were in Rutherford class IV, 208 (43.3%) in class V and 179 (37.4%) in class VI. Surgical, endovascular and hybrid operations were performed in 108 (22.5%), 319 (66.5%) and 53 (11%) patients, respectively; mean follow-up was 408 ± 363 days. Improved or unchanged functional status was observed in 276 patients (57.5%). Preoperative mean ± SD BADL and IADL (4.26 ± 1.98 and 3.92 ± 2.69, respectively) were modified from mean values at 1-year follow-up (4.19 ± 2.06 and 4.12 ± 3, respectively) (p = 0.401 and p < 0.05, respectively). In the same time interval, mortality was 50%, limb salvage 50.4%, CLI-related new hospitalisations 50.8%, relief of symptoms 18.5% and tissue healing 14.5%. A CLI functional score of >80% indicates that patients are likely to lose functional abilities and require assistance for ambulation or ADL, as well as risking outcomes such as major amputation, new CLI-related hospitalisation or re-operation (p < 0.001). Preoperative poor living status, dependence in daily activities, advanced local disease (lesion >2 cm, infection and poor tibial runoff), American Society of Anesthesiologists (ASA) score > II, previous cerebrovascular event and heart disease were the strongest pre-operative negative predictors of losing baseline functional status. Major amputation was the only negative post-operative predictor. CONCLUSIONS: Considering patient-oriented outcomes, our study showed that revascularisation could be worthwhile in nearly 60% of CLI patients. A non-revascularisation strategy such as primary amputation or palliation could be indicated in patients with a poor pre-operative living status, dependence for daily activities, advanced local disease, extensive comorbid conditions and a score >80%. To make our findings generalisable, the score needs to be validated in independent cohorts at different centres before it can be recommended for application.

AAA with a challenging neck: early outcomes using the Endurant stent-graft system.

OBJECTIVES: The efficacy and safety of endovascular aneurysm repair is disputable in aneurysms with a short, angulated, wide, conical, or thrombus-lined neck making a reliable seal difficult to achieve. The influence of a challenging neck on early results using the Endurant stent-graft system in high risk patients was investigated. MATERIALS AND METHODS: A retrospective study conducted on a prospectively compiled database of 72 elective patients with challenging neck treated with the Endurant system (Endurant Stent Graft, Medtronic AVE, Santa Rosa, CA, USA). These patients were compared to a control group (n = 65) without significant neck problems. Endpoints were early technical and clinical success, deployment accuracy and differences in operative details at one month follow-up. Data are reported as mean and standard deviation or as absolute frequency and percentage (%). Normality distribution and homogeneity of variances were tested by Shapiro-Wilks and Levene tests, respectively. Inter-group comparisons for each variable were made by t-test or χ2-test or Fisher exact test. A p < 0.05 was considered statistically significant. RESULTS: Mean age was 76.12 years; 76.6% were males. Risk factors and pre-operative variables did not differ significantly between the two groups. Mean neck length was 10.56 mm in patients with challenging anatomies and 22.85 mm in controls. Patients with a challenging neck differed significantly (p < 0.001) from controls in terms of mean infrarenal (37.67° vs. 20.12°) and suprarenal angle (19.63° vs. 15.57°); 82% of patients with a challenging neck were ASA III/IV (vs. 86%). Technical success was 100%, with four unplanned proximal extension in challenging group. No type I endoleaks or aneurysm-related deaths occurred in either group; major complications were 1.54% vs. 1.39% (p = 0.942). Operative details were similar in both groups. CONCLUSION: Treatment with the Endurant stent-graft is technically feasible and safe, yielding satisfactory results even in challenging anatomies. Medium- and long-term data are needed to verify durability, but early results are promising.

Open vascular surgery as a starting point for endovascular surgery.

What distinguishes vascular surgeons from other specialists who treat patients with vascular disease is their ability to combine skills in both open and endovascular treatments. Open vascular surgery should be considered the "starting point" for endovascular surgery, since training and practice in vascular surgery require extensive knowledge of the basic science and a thorough education in general surgical techniques. In addition, surgeons must possess detailed specialized knowledge of the anatomy and physiology of arteries, veins and lymphatics and of the pathological processes which may affect them. This scientific and technical background is also imperative for endovascular surgery. Open vascular surgery can also be considered as a potential finishing point of endovascular surgery. In fact, open surgery is still often the only solution for complex cases considered unsuitable for an endovascular approach, or for different types of complications following endovascular treatments. As endovascular surgery is increasingly considered as the initial treatment option for many patients with vascular disease, it is crucial that vascular surgery training programs develop methods to maintain the open surgical skills of their trainees. The only way for vascular surgeons to remain the premier specialists to care for patients with vascular disease is for them to combine skills in both open and endovascular treatments.

A new idea for a safer approach to the supra-aortic trunks: the Piton™ catheter.

Carotid artery disease is among the most common causes of stroke, and stroke is the third leading cause of death in industrialized countries. Thus the personal health and socioeconomic burden of carotid artery disease is significant. Carotid artery disease accounts for approximately 5-12% of new strokes in patients amenable to revascularization therapy. Atherosclerosis is the main reason for stroke and accounts for approximately one third of all cases. Carotid stenting is nowadays considered a valid standard alternative to surgical carotid endarterectomy, especially in patients having a high perioperative risk. The first carotid balloon angioplasty was carried out in 1979 and the first carotid balloon-expandable bare metal stents were implanted 10 years later, in 1989. However, carotid stenting at that time was associated with major complications, due to extrinsic compression and subsequent to the steel stents used. The Piton™ GC (carotid guide catheter) is intended to facilitate the introduction and placement of interventional devices (e.g., guidewires, stent delivery systems, dilation balloons, angiographic- or micro-catheters, etc.) into the human vasculature to treat vascular obstructive disease, including but not limited to the supra-aortic vessels.

Renal aneurysms: surgical vs. endovascular treatment.

Renal artery aneurysms (RAA) are rare (general population incidence is 0.09%). At this time, the appropriateness of the type of intervention ­ surgical or endovascular ­ is based on single center experiences rather than large randomized trials. Endovascular therapy offers less morbidity but surgery has excellent long-term results. In reality, the choice of the treatment relies on the operative risk. A patient with a RAA and good surgical risk should be offered open surgery. If the patient is deemed to be at high risk from surgery then the choice of the type of endovascular treatment (stent grafting, coil/glue embolization, multilayer stenting) should be based on the location and shape of the RAA. RAA should be treated by surgeons/interventionalists who have demonstrated expertise in renal artery procedures.

Proctorship for CAS training: a pilot study of safety and reproducibility.

AIM: The literature continues reporting a high complication rate for carotid artery stenting (CAS) during the learning-curve phase (LCP). The aim of this study was to report a simple and reproducible method designed to improve CAS results during the LCP. METHODS: Between February 2007 and December 2009, a qualified vascular surgeon ran a proctorship program for CAS. The program was divided into four practical phases: in the teaching phase (a) the first 20 CAS were performed by the proctor assisted by a trainee surgeon; in the training phase (b) for the 21st to the 50th CAS the trainee surgeon was supervised by the proctor; in the skilled phase (c), between the 51st and the 80th procedure, a trainee surgeon performed CAS while the proctor was scrubbed-in but operating only on demand; in the final phase (d), following the 81st CAS, the procedure was performed without the proctor's presence. The inclusion criterion was carotid stenosis ≥70% and patient selection was performed for the first 40 cases based on patient and lesion characteristics. The procedure for CAS was standardized. RESULTS: Four trainees performed 604 CASs in two centers. The procedural success rate of CAS was 98.8% (N.=594/604) without any differences among the four trainees (P=0.902). The overall TIA, myocardial infarction, minor, major and fatal stroke rate at 30 days was respectively 1.7% (N.=10), 0.8% (N.=5), 1.2% (N.=7), 0.64% (N.=4) and 0.3% (N.=2). The effectiveness of this program was demonstrated by a significant decrease in the proctor's intervention between phase b and phase c (P<0.001) and by a similar trend in the complication rate achieved by the four trainees, in all phases and centers (P=0.075 and 0.788, respectively). CONCLUSION: This preliminary experience of a proctorship program in the LCP, together with patient selection and standardization of the procedure and materials used, seems to be safe and reproducible. Moreover, possibly randomized, studies comparing different CAS training techniques are needed in order to validate our findings.

Ischemic foot: definition, etiology and angiosome concept.

Ischemic foot is a condition of decreased arterial perfusion. It has several etiologies, atherosclerotic peripheral arterial disease, including that secondary to diabetes mellitus, being the most common. Other potential causes of ischemic foot are acute embolism from cardiac, arterial or paradoxical sources, and thrombosis secondary to arterial blood clots due to procoagulative states (e.g. vasculitis and hematologic disorders), arterial spasms or injury resulting from drug use or from external or iatrogenic trauma. Prompt diagnosis and revascularization of the affected limb play a crucial role in the treatment of ischemic foot. The angiosome principle, defined by Ian Taylor's landmark anatomic study in 1987, divides the body into three-dimensional anatomic units of tissue fed by a source artery (the angiosome). Detailed knowledge of the vascular anatomy of the leg, and in particular of angiosomes in the foot, helps the clinician make better decisions when dealing with ischemic foot. The physician can better estimate the possibility of wound healing, and decide which type of revascularization has the most chance of success, given the existing blood supply. If surgical or endovascular revascularization is successful, the foot should no longer appear ischemic and painful, and the wounds should granulate. Newly granulating wounds should be carefully protected, and meticulous daily local wound care should be performed to promote healing and prevent infection. The quality of subsequent wound care is also a critical component in promoting healing and avoiding further tissue loss.

Acute aortic dissection: natural history and classification.

Acute aortic dissection is an uncommon but potentially catastrophic pathology with high mortality and morbidity. Significant advances in the understanding, diagnosis and management of aortic dissection have been made since the first case was reported 3 centuries ago. This article aims to review our current understanding of the natural history and classification of acute aortic dissection.

Hybrid procedures for acute limb ischemia.

The most efficient treatment for acute arterial embolism is operative embolectomy using Fogarty's balloon catheter, especially if a single large artery is involved. Unfortunately, although the early surgical success of arterial thromboembolectomy often seems acceptable, the early clinical outcome still remains unsatisfactory. This may be related to the incomplete restoration of perfusion (i.e., residual thrombus in distal vessels not reached by the balloon catheter thromboembolectomy), propagation of residual thrombi or presence of underlying steno-occlusive lesions. In such a situation a meticulous intraoperative assessment of the adequacy of clot removal is decisive. Residual thrombus, chronic atherosclerotic disease and even vessel injuries secondary to balloon catheter passage can be corrected by endovascular techniques (hybrid procedures). The combination of surgical and endovascular options may overcome the limitations that characterize the traditional approach, and it is likely that in the future many treatments will be a mix of techniques that can be performed by vascular surgeons in the operating room or in a dedicated endovascular suite. This review article summarizes the hybrid treatment options for acute arterial occlusion caused by either embolism or local thrombosis.

Endovascular approach for ruptured abdominal aortic aneursyms.

The rupture of an abdominal aortic aneurysm (rAAA) causes about 15000 deaths/year in the USA alone. Even though over the last 50 years progress in surgical techniques and in postoperative intensive care have been outstanding, the analysis of registries has shown either no decrease in the mortality rate for surgically treated rAAAs. Some reports asserted better out come for endovascular repair (EVAR) compared with surgery in case of rAAA. Despite this evidence, EVAR for rAAA remains prerogative of few centers worldwide. In conclusion only larger study or registry could assest the real role of EVAR in the management of rAAA.

Management of abdominal endograft infection.

Incidence, clinical presentation and management of aortic grafts infection after open surgical repair are well described in the literature. Infective complications involving endografts after endovascular aneurysm repair (EVAR) have been scarcely investigated, since more attention has been given to the technical aspects of the procedure, including endoleaks, device migration, neck dilatation, endotension and aneurysm rupture. Nevertheless, that is a rare but severe complication occurring after EVAR; potentially difficult to diagnose and treat. Since 1991 only 102 cases of abdominal endograft infections have been reported in the literature. Treatment of infected abdominal endografts is controversial. Although reports have shown that high-risk patients with infected stent grafts treated conservatively with antimicrobial therapy and percutaneous drainage can still survive, most authors agree that an infected endograft should be removed if patient's conditions allow intervention. Standard treatment for infected abdominal endografts includes complete graft excision and local debridement followed by extra-anatomical bypass revascularization or in situ reconstruction with an aortic-bisiliac or bifemoral graft (Dacron or PTFE) or with a homograft. Lower overall mortality was observed for surgical management by explantation of infected endograft followed by in situ replacement as compared to other surgical solutions, but no definitive conclusions can be drawn about the optimal treatment strategy for aortic reconstruction.

Endovascular thoracic aortic repair and risk of spinal cord ischemia: the role of previous or concomitant treatment for aortic aneurysm.

Spinal cord ischemia (SCI) is one of the most devastating complications undergoing surgical or endovascular repair of the thoracic aorta. The incidence of SCI after thoracic aorta open repair varies from 2% to 21%, depending on the extent of the descending thoracic aorta replacement compared with as high as 12% of cases after endovascular aortic repair. Endoluminal repair allows the avoidance of aortic cross clamping and its sequelae; however, the intercostal arteries covered by the stent graft cannot be reimplanted. Perioperative risk factors contributing to SCI have been reported to include length of aortic coverage, prior abdominal aortic aneurysm (AAA) repair, hypotension, and left subclavian artery coverage. Although the putative mechanism of loss of lumbar collateral perfusion in those who had prior aortic repairs appears reasonable, occurrence of SCI in this subset of patients has not been consistent. Spinal cord perfusion is dependent on the net pressure of the mean arterial pressure minus the mean intrathecal pressure. Systemic pressure can be maximized by volume resuscitation and vasopressors. Intrathecal spinal pressure can be minimized by drainage of the spinal cord, although this is not without its potential risks. More recently, there have been attempts at attenuating the cellular damage caused by SCI, either with systemic or intrathecal administration of pharmacologic agents, which attempt to mitigate the inflammatory response of cellular reperfusion. This is a review of the risk factors for SCI during TEVAR in patients with previous or concomitant treatment for aortic aneurysm.

Focusing on Diabetic Ulcers.

Foot ulcers associated with Diabetes mellitus require immediate attention due to risk of amputation if left untreated. Herein we focus on the mitigating risk factors and physiopathology of the diabetic foot, recounting our own surgical approach and revascularization procedures.

Acute Deep Vein Thrombosis and Pulmonary Embolism: is the Thromboaspiration Device an Appropriate Choice?

Nowadays patients affected by deep vein thrombosis (DVT) and pulmonary embolism (PE) are studied widely but the challenge for physicians is when and how they are to be treated. Most patients present serious comorbidities that can potentially make treatment difficult. An increasing cohort of patients cannot be treated with systemic fibrinolysis but fortunately today, physicians can utilize a number of different instruments to resolve acute DVT and PE.

Subintimal angioplasty with the aid of a re-entry device for TASC C and D lesions of the SFA.

AIM: The aim of this prospective study was to assess the clinical effectiveness and related midterm patency of subintimal angioplasty (SAP) in patients suffering from critical limb ischaemia (CLI) in a single tertiary care university centre. The secondary aim was to evaluate the safety and clinical effectiveness of using a re-entry device when re-canalisation by SAP was unsuccessful. METHODS: From January 2005 to December 2007, consecutive patients suffering from CLI (Rutherford clinical categories: 4-6) were treated with SAP. All patients included in the study had occluded SFA (TASC C and D) and underwent clinical and ultrasound follow-up examinations at day 30 and at 3, 6, 9 and 12 months, and then yearly. A re-entry device (Outback, Cordis Corporation, Miami Lakes, Florida, USA in all cases) was only used when re-canalisation by simple SAP was unsuccessful, and stenting was used when residual stenosis was >30% or there was a flow-limiting dissection. Factors that could modify the outcome were analysed. RESULTS: In this study, 145 patients were treated, with a technical success rate of 83.5% (121 of 145) for simple SAP. Stenting was performed in 43% (n=62) of successful SAP procedures. No death occurred in the perioperative period, while the 30-day mortality was 4.8% (7 of 145). The re-entry device (Outback) was used in 24 cases (16.5%). The technical success of the re-entry device was 79% (19 of 24), with a 90% success rate of stent placement at the site of re-entry. Complications occurred in 6.2% of all procedures (n=9) (three arterial perforations (2.1%), three distal embolisations (2.1%), two femoral artery pseudo-aneurysms (1.4%) and one arterio-venous fistula (0.7%)). Factors capable of independently affecting the patency were renal insufficiency (p=0.03), current smoking (p=0.01) and diabetes (p=0.04). The primary patency at 1 and 3 years was 70% and 34% and the secondary patency at 1 and 3 years was 77% and 43%, respectively. At the same time intervals, the limb-salvage rate was 88% and 49%. CONCLUSIONS: SAP with the aid of a re-entry device for TASC C and D lesions of the SFA seems to be safe and clinically effective in patients suffering from CLI, according to the experience at our centre. Further follow-up and more data are necessary to confirm these findings.

Diabetic patients: epidemiology and global impact.

Definition of the exact epidemiology and the global impact of diabetes is not easy, being strictly related to the availability of data in developing countries and to the use in the existing population-based investigations of common criteria for the diagnosis and definition of diabetes. According to the World Health Organization (WHO) the total number of people with diabetes was 171 million in 2000, and is projected to rise up to 366 million in 2030. The true prevalence of peripheral arterial disease (PAD) in people with diabetes has been difficult to determine, as most patients are asymptomatic, many do not report their symptoms, screening modalities have not been uniformly agreed upon, and pain perception may be blunted by the presence of peripheral neuropathy. Population-based studies, using a validated and reproducible test, have revealed a prevalence of PAD in people with diabetes to be up to 30%. Among people with diabetes, the annual incidence of developing a foot ulcer ranges from 1% to 4.1% and the prevalence ranges from 4% to 10%, which suggests that the lifetime incidence may be as high as 25%. Foot ulcer associated to PAD requires revascularization, although it is generally considered that the outcome in those people is inferior to that in non-diabetic patients. In summary, the increasing worldwide diabetes prevalence will inevitably result in increasing proportions of deaths from cardiovascular disease, as well as in increased prevalence and associated consequences of other complications of diabetes. As suggested by WHO, a concerted, global initiative is required to address the diabetes epidemic.