Prevalence, risk factors and clinical impact of intraprosthetic thrombus deposits after EVAR.

BACKGROUND: The aim was to define the prevalence, the evolution and the clinical relevance of the intraprosthetic thrombus deposit (IPT) after endovascular abdominal aortic repair (EVAR). METHODS: Patients treated with EVAR from 2009 to 2017 for abdominal aortic aneurysm were retrospectively considered. Patients with at least one postoperative computed tomography angiography (CTA) performed after a 3-month follow-up were included. Postoperative medical therapy (antiplatelet and/or oral anticoagulant) were recorded. Aorto-iliac anatomical characteristics were measured on pre-operative CTA, while structural and dimensional endograft features were extracted from instructions for use. IPT was defined as intra-endograft thrombus with minimum thickness of 2mm and longitudinally extended for minimum 4 mm, and was assessed in all postoperative CTA. Primary endpoints were freedom from IPT occurrence, risk factors for IPT and evolution of IPT. Secondary endpoints were the prevalence of overall and IPT-related tromboembolic events (TEE: main-body or limb occlusion, distal embolization) during follow-up and its correlation with IPT. RESULTS: Two-hundred twenty-one patients (mean age 76±7 years; male 94%) were included. Deployed endografts were: aorto-biiliac 96%, aorto-uniiliac 3%, aortic tube 1%; dacron 90%, ePTFE 10%. Mean follow-up was 30±25 months. Overall IPT prevalence was 36% (80/221). At 6, 12, 24 and 48 months, overall estimated freedom from IPT occurrence was 86%, 80%, 60% and 52%, respectively (Kaplan-Meier analysis). At Cox uni-variate analysis, postoperative medical therapy has no influence on IPT; aorto-iliac anatomical risk factors for IPT were larger neck diameter (P<0.001), severe neck thrombus (P=0.043), higher percentage of sac thrombus (P<0.001), hypogastric occlusion/coverage (P=0.040); endograft risk factors were proximal diameter ≥30mm (P<0.001), longer main body (P=0.002), dacron fabric (P=0.025), higher ratio between main body area/gate areas and main body area/distal iliac areas (P<0.001 and P<0.001, respectively). At Cox multi-variate analysis, independent risk factors for IPT were larger neck diameter (P=0.003), higher percentage of sac thrombus (P=0.005) and longer main body (P=0.028). During follow-up, IPT disappeared in 14 cases (18%). Overall TEE prevalence was 4% (8/221) and overall estimated freedom from TEE occurrence at 6, 12, 24 and 48 months was 99%, 99%, 95.3%, 94.1%, respectively (Kaplan-Meier analysis). TEE was IPT-related in 5/8 cases (63%). No statistical correlation were found between IPT and TEE. CONCLUSIONS: The development of intraprosthetic graft thrombus (IPT) is a frequent event after EVAR. The risk of IPT is closely correlated with the proximal aortic neck size, the presence of intra-aneurysmal sac thrombus, and the length of the endograft main body. However, there was no statistical correlation between the presence of IPT and TEE.

Twelve years of experience in carotid endarterectomy with general anesthesia and preserved consciousness.

BACKGROUND: Carotid endarterectomy (CEA) can be performed both under general anesthesia (GA) or local anesthesia (LA) with good results. General anesthesia with preserved consciousness (GAPC) using remifentanil infusion has been already reported in literature and could potentially merge the advantages of GA and LA overcoming the disadvantages of this last technique. Although the good results of GAPC reported in literature, this technique is not widespread in clinical practice. The aim of this study was to report the perioperative results of CEA under GAPC in a large series of consecutive patients. METHODS: This is a retrospective, single center, observational study including all patients treated for CEA under GAPC in our institution between January 2008 and October 2019. Primary endpoints were neurological complications rate, mortality rate in the perioperative period, need to GAPC conversion to GA during surgery and evaluation of the technique with a specific questionnaire regarding patients' satisfaction. Secondary endpoints were myocardial infarction (MI) rate, other perioperative complications rate, rate of intraoperative shunting and need of reintervention in the perioperative period. RESULTS: In the considered period 1290 CEA under GAPC were performed and included in this study. Neurological complications rate was 2.01%, mortality rate in the perioperative period was 0.07%, need of GAPC conversion to GA rate during surgery was 0.46% and patients satisfaction regarding the technique were high with a mean vote of 9.1 in a 0 to 10 scale. In the perioperative period MI rate was 0.23%, other perioperative complications rate was 1.39%, intraoperative shunting rate was 7.1% and reintervention rate after surgery was 2.4%. CONCLUSIONS: CEA under GAPC may combine the advantages of LA and GA, with a very low rate of conversion to GA during surgery and good patients' satisfaction. Moreover, it does not increase neurological, cardiologic and systemic complications. For these reasons CEA under GAPC could represents a valid alternative to GA or LA.