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Large mediastinal lipomas are rare. Complete surgical resection can be difficult due to the intricate anatomy in the mediastinum. We report the case of a 75-year-old man with worsened retrosternal pressure, decline in performance and syncope episodes. Computed tomography revealed a large retrocardiac low-attenuated mediastinal lesion measuring 10 × 8 cm, compressing the left atrium and pulmonary veins bilaterally. Surgical exploration was achieved through a right anterolateral thoracotomy with a successful en bloc resection without any intraoperative complications. The total operation time was 185 min with a total blood loss of <250 ml. Stand-by extracorporeal life support was present throughout the procedure, but its use was not required. The postoperative course was uneventful. The pathological examination revealed a mature mediastinal lipoma without any evidence of malignancy. In the 12-month control the patient was completely free of symptoms and in a good general condition.
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OBJECTIVE: To assess the initial clinical experience with a novel endograft system (NEXUS Aortic Arch Stent Graft System) designed to treat aortic arch pathologies and address the morphology and hemodynamic challenges of the aortic arch. SUMMARY BACKGROUND DATA: The aortic arch remains the most challenging part of the aorta for both open and endovascular repair. Transcatheter aortic arch repair has the potential to significantly reduce surgical risks. METHODS: Patients underwent transcatheter aortic arch repair with a single branch, 2 stent graft system, implanted over a through-and-through guidewire from the brachiocephalic trunk, to the descending aorta with an ascending aorta stent graft. The ascending aorta stent graft is deployed into a designated docking sleeve to connect the 2 stent grafts and isolate the aortic arch pathology. Proximal landing zone in all cases was in Zone 0. Anatomical inclusion criteria included adequate landing zone in the ascending aorta, brachiocephalic trunk, and descending thoracic aorta. Preparatory debranching procedure was performed in all patients with carotid-carotid crossover bypass and left carotid to left subclavian bypass, or parallel graft from descending aorta to left subclavian artery. Safety and performance were evaluated through 1 year. Survival analysis used the Kaplan-Meier method. RESULTS: Twenty-eight patients, 79% males, with a mean age of 72.2 ± 6.2 years were treated with 100% procedural success. Isolated aortic arch aneurysm was the principle pathology in 17 (60.7%) of patients, while chronic aortic dissection was the principle pathology in 6 (21.4%) of patients. The remaining 5 (17.8%) had combined or other pathologies. At 1 month, the vascular pathology was excluded in 25 of 26 alive patients (96.1%). The 30 days mortality rate was 7.1%, stroke rate was 3.6% (all nondisabling), and combined mortality/stroke rate was 10.7%. One-year mortality was 10.7%, without device or aneurysm-related death. Two patients (7.1%) reported stroke or transient ischemic attack at 1 year that recovered completely. One year combined mortality/stroke rate was 17.8%. There were 3 patients (10.7%) that had device-related unplanned reinterventions through 1 year. CONCLUSIONS: The NEXUS Aortic Arch Stent Graft System, a novel single branch, 2 stent graft system used for endovascular aortic arch repair that requires landing in the ascending aorta, demonstrates a high success rate with excellent 1 year safety and performance.
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Disección Aórtica , Accidente Cerebrovascular , Masculino , Humanos , Anciano , Femenino , Aorta Torácica/cirugía , Aorta , Stents , Disección Aórtica/cirugíaRESUMEN
OBJECTIVES: Endovascular aortic arch stent grafting with branched devices has shown initial promising results. The aim of this prospective, multicentre study was to evaluate 3-year outcomes of aortic arch stent grafting with NEXUS® Aortic Arch Stent Graft System (Nexus), a single-branch, bi-modular, off-the-shelf aortic arch stent graft system in high-risk patients. METHODS: Patients treated with Nexus, either under the feasibility clinical study or as compassionate use procedures in 5 centres, were included in this study. The primary end point was overall survival. The secondary end points included the incidence of procedure-related unplanned intervention, stroke, paraplegia and endoleak. Clinical and radiologic follow-up was performed at each study site at 30 days, 6 months and on a yearly basis thereafter up to 3 years postoperatively. RESULTS: We analysed data from a total of 28 patients. The overall median follow-up was 1132 (interquartile range: 809-1537). There were no device or procedure-related deaths between 1 and 3 years. Overall survival at 1 and 3 years was 89% and 71%, respectively. The cumulative incidence of unplanned reintervention at 1 and 3 years was 11% and 29%, respectively. There were no reports of stroke, paraplegia, aneurysm rupture, myocardial infarction or new aortic valve insufficiency. In this study's 1-3 year follow-up period, 1 type Ib (4%), 1 type II (4%) and 2 type III (8%; between Nexus' distal end and Thoracic endovascular aortic repair (TEVAR) extensions) endoleak were detected. CONCLUSIONS: Endovascular aortic arch exclusion with the single-branch, off-the-shelf Nexus system provides promising clinical and radiologic results at 3-year follow-up in a high-risk patient cohort.
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Aneurisma de la Aorta Torácica , Disección Aórtica , Implantación de Prótesis Vascular , Procedimientos Endovasculares , Accidente Cerebrovascular , Humanos , Prótesis Vascular/efectos adversos , Endofuga/epidemiología , Endofuga/etiología , Reparación Endovascular de Aneurismas , Estudios de Seguimiento , Estudios Prospectivos , Complicaciones Posoperatorias , Stents/efectos adversos , Accidente Cerebrovascular/etiología , Resultado del Tratamiento , Estudios RetrospectivosRESUMEN
BACKGROUND: Hybrid treatments (HT) aim to reduce conventional open surgery invasiveness and address multilevel peripheral arterial disease (PAD). Herein, the simultaneous HT treatment in patients with chronic limb-threatening ischemia (CLTI) is reported. METHODS: Retrospective analysis, for the period from May 2012 to April 2018, of patients presenting multilevel PAD with CLTI addressed with simultaneous HT. The outcomes of these interventions were measured the following metrics: early technical successes (within 30 days following treatment) and late technical successes (30 days or more following treatment) and included mortality, morbidity symptoms recurrence, and amputation. Survival and patencies were estimated. The median follow-up was 43.77 months. RESULTS: In the 45 included patients, the HT consisted of femoral bifurcation patch angioplasty followed by an endovascular treatment in 38 patients (84.4%) and endovascular treatment followed by a surgical bypass in 7 patients (15.6%). Technical success was 100% without perioperative mortality. Eight (17.8%) patients presented early complications without major amputations. During the follow-up, seven (15.6%) deaths occurred and six patients (13.3%) experienced symptoms recurrence, with five of those patients requiring major amputation. An estimated survival time of 5 years, primary patency, and secondary patency was 84.4%, 79.2%, and 83.3% respectively. CONCLUSIONS: Hybrid treatments are effective in addressing patients presenting with multilevel PAD and CLTI. The common femoral artery involvement influences strategy selection. Larger studies with longer-term outcomes are required to validate the hybrid approach, indications, and results.
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Infection with Echinococcus granulosus is a common helminthic disease worldwide with endemic in a region with high endemic areas in Africa, Asia, Middle East, South America and southern Europe. We report a rare case of a young patient with cystic echinococcal disease of the liver invading the pericardium. The patient initially presented with life-threatening cardiac tamponade, which resulted in the discovery of the underlying parasitic disease. He successfully underwent en-bloc hepatic pericystectomy and pericardiac resection with closure of the pericardial defect using a xenogeneic patch. After this procedure, he recovered well and had no cardiac complications in the long term. Under treatment with albendazol, the patient showed no signs of recurrent disease. Cases of complex cystic echinococcosis, which invade adjacent organs or body cavities, often need radical surgery for definitive treatment embedded in a multidisciplinary approach in highly specialized centers.
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INTRODUCTION: Post-operative anastomotic pseudo-aneurysms are rare but potentially lethal complications after the Bentall procedure. When symptomatic or ruptured, expedited repair is warranted, and open surgery may carry significant bleeding risk, particularly when these lesions project anteriorly. As totally endovascular techniques are frequently limited owing to hostile anatomies, complex hybrid interventions are an alternative option in such scenarios. REPORT: A 53 year old man with a previous Bentall procedure performed 10 years previously for DeBakey type 1 dissection was admitted with chest pain. Computed tomography angiography revealed a distal anastomotic pseudo-aneurysm. Percutaneous pseudo-aneurysm occlusion with a septal occluder plug was performed initially, with significant clinical improvement but without total sac thrombosis. The patient was discharged under strict surveillance, but six months later was re-admitted owing to hoarseness and new onset of chest pain. As the patient developed acute pain and compressive symptoms, urgent treatment was required. As the pseudo-aneurysm projected anteriorly into the posterior aspect of sternum, significantly bleeding risk was anticipated with redo sternotomy. A hybrid repair was then planned, with a full supra-aortic trunk debranching (carotid-carotid and left carotid-subclavian bypass) and zone 0 TEVAR with a single parallel graft to the brachiocephalic trunk. The patient was discharged 10 days later. Total aneurysm exclusion was achieved, with no complications reported after six months follow up. DISCUSSION: Hybrid procedures may represent a safe and feasible alternative to open surgery in symptomatic ascending aortic pseudo-aneurysms. However, long term follow up studies are required to confirm the durability of these procedures.
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INTRODUCTION: Spontaneous acute aortic syndrome (IAAS) is rarely localized in the infrarenal aorta. The endovascular approach is preferred over conventional open surgery with fewer complications. However, dedicated endovascular devices for IAAS treatment are unavailable. The aim was to report a large single-center experience using unibody stent-grafts to address IAAS. METHODS: From April 2016 to March 2019, a retrospective analysis of patients presenting spontaneous and isolated IAAS was performed. Patients addressed with the unibody stent-graft (AFX endovascular AAA system; Endologix Inc., Irvine, CA) were included in the study. Indications to IAAS treatment were persistent symptoms and/or dilated abdominal aorta (>3 cm). The measured outcomes were technical success; early outcomes (<30 days) including mortality, morbidity, symptoms recurrence, and endoleak occurrence; and late outcomes (>30 days) including mortality, symptoms recurrence, endoleak occurrence, stent-graft patency, and survival. Median follow-up was 23.77 ± 10 months. RESULTS: Twenty-one patients with IAAS were included. Indications to treatment were symptoms in 14 (67%) patients and dilated abdominal aorta in 7 (33%). Technical success was achieved in all cases. No perioperative mortality and 1 (4.8%) early femoral access complication was encountered. During the follow-up were registered 1 (4.8%) aortic unrelated death and 1 (4.8%) stent-graft limb stenosis. The 36 months estimated survival and freedom from reintervention were 92% (CI: 37-43; SE: 1.7) and 94% (CI: 37-44; SE: 1.7), respectively. CONCLUSIONS: The endovascular treatment of IAAS with unibody stent-graft (AFX endovascular AAA system; Endologix Inc.) is safe and effective with promising mid-term outcomes. The use of unibody stent-grafts expands the endovascular indication, despite the usual anatomic IAAS features. Larger studies with longer follow-up are required to validate the outcomes of the reported technique.
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Aneurisma de la Aorta Abdominal , Implantación de Prótesis Vascular , Procedimientos Endovasculares , Aorta Abdominal/diagnóstico por imagen , Aorta Abdominal/cirugía , Aneurisma de la Aorta Abdominal/cirugía , Prótesis Vascular , Humanos , Diseño de Prótesis , Estudios Retrospectivos , Stents , Resultado del TratamientoAsunto(s)
Aneurisma de la Aorta Abdominal/cirugía , Implantación de Prótesis Vascular , Procedimientos Endovasculares , Aneurisma de la Aorta Abdominal/diagnóstico por imagen , Prótesis Vascular , Implantación de Prótesis Vascular/efectos adversos , Implantación de Prótesis Vascular/instrumentación , Endofuga/etiología , Procedimientos Endovasculares/efectos adversos , Procedimientos Endovasculares/instrumentación , Medicina Basada en la Evidencia , Humanos , Sistema de Registros , Medición de Riesgo , Factores de Riesgo , Stents , Resultado del TratamientoRESUMEN
BACKGROUND: The aim of this study was to report the feasibility and outcomes with the endovascular treatment of spontaneous internal carotid artery dissections (ICADs) using a proximal embolic protection device (EPD). METHODS: This is a retrospective analysis of patients treated for spontaneous symptomatic ICAD using a proximal EPD from January 2017 to December 2018. Indication for treatment was the presence of neurologic symptoms. Early outcomes measured included technical success, perioperative mortality, and major cardiovascular or cerebrovascular complications. Late outcomes were recurrent neurologic symptoms, patency, and reinterventions. RESULTS: A total of 4 male patients with ICAD were included. A preoperative cerebral computed tomography positive for cerebral ischemic events was reported in all cases. In 3 patients, the neurologic symptoms consisted of a transient ischemic attack; the remaining patient presented an amaurosis fugax and aphasia. In 2 patients, ICAD was associated with a carotid significant stenosis. In all patients, the reported approach was feasible with no complications and complete anatomic dissection resolution. At a mean follow-up of 18 months, all stents are patent and no restenosis recurrence or complications were registered. CONCLUSIONS: The use of proximal EPDs allowed the treatment of ICAD under flow arrest, minimizing the risk of stroke during the endovascular maneuvers. Larger series are required to validate this treatment strategy.
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Disección de la Arteria Carótida Interna/terapia , Arteria Carótida Interna , Estenosis Carotídea/terapia , Dispositivos de Protección Embólica , Procedimientos Endovasculares/instrumentación , Stents , Amaurosis Fugax/etiología , Afasia/etiología , Arteria Carótida Interna/diagnóstico por imagen , Disección de la Arteria Carótida Interna/complicaciones , Disección de la Arteria Carótida Interna/diagnóstico por imagen , Estenosis Carotídea/complicaciones , Estenosis Carotídea/diagnóstico por imagen , Humanos , Ataque Isquémico Transitorio/etiología , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
Background: To present a technique of sheath supported contralateral limb gate (CLG) cannulation of modular bifurcated stent-graft in endovascular abdominal aortic repair. Materials and methods: After totally percutaneous bilateral femoral access, the 9F introducer sheath is exchanged to a 30 cm 12 fr introducer sheath over a stiff wire contralateral to the intended main stent-graft insertion side and advanced into the aorta below the lowest renal artery. Parallel to the stiff wire within the sheath an additional standard J-tip guidewire with a 5 fr Pigtail angiographic catheter is advanced to the level of the renal arteries. After main body deployment, the 12 fr introducer sheath and J-tip wire with pigtail catheter are retracted until the CLG opening level, maintaining the stiff "buddy" wire in position to support the 12 fr sheath, maintaining its distal opening close to the contralateral gate opening to achieve easy cannulation. Results: Retrospective analysis of video archive from July 2016 to February 2018 evidenced 55 recorded EVAR cases. All CLG cannulations were obtained with Standard J-tip or Terumo Glidewire wires and with Pig-Tail or Berenstein catheters. Technical success was 100 %. Mean fluoroscopy time to accomplish CLG cannulation was 37.6 33 (range 1-105) seconds. The aortic carrefour angulation on coronal axis strongly correlates with cannulation time p = <.001, with longer cannulation time for higher carrefour angulations on coronal axis (Pearson correlation coefficient 0.47). Conclusions: The use of 12 fr sheath with parallel wire introduction technique, appears to be a safe and reliable tool to facilitate CLG cannulation during EVAR procedures.
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Aneurisma de la Aorta Abdominal , Implantación de Prótesis Vascular , Procedimientos Endovasculares , Prótesis Vascular , Humanos , Estudios Retrospectivos , Stents , Resultado del TratamientoRESUMEN
Purpose: To evaluate the feasibility of a patient-specific rehearsal (PsR) before emergency endovascular aneurysm repairs (eEVAR) and its influence on the operation. Materials and Methods: From February 2016 to October 2016, 10 consecutive patients (mean age 75±7.4 years; 9 men) presenting with a ruptured abdominal aortic aneurysm (rAAA) suitable for standard EVAR were enrolled in the study. A 3-dimensional (3D) model of the abdominal aorta was generated on a virtual reality simulator based on the patient's computed tomography (CT) images. Following the patient-specific simulation setup, PsR was conducted during patient admission or in parallel with the preoperative eEVAR workup. Measured outcomes were PsR feasibility only in the first 4 patients and impact on operative performance thereafter (changes in device selection, the planning process, clinical outcomes, perioperative mortality, and complication rates). Technical metrics and timing of system setup, rehearsal, interval from patient arrival to the actual procedure, and eEVAR were recorded. Results: Mean time for 3D model creation was 21.3±7.8 minutes (range 13-37); there was a significant positive relationship between aortic neck diameter and segmentation time (p=0.003). The overall mean time for simulator setup and PsR was 54±14 minutes (range 37-80); PsR alone was completed in a mean 31±40 minutes (95% confidence interval -60 to -2.2). The actual eEVAR procedure duration was 69±16 minutes (range 45-90). No delay in the actual eEVAR procedure was registered owing to the PsR pathway. In 6 patients, preprocedure rehearsal induced changes in operative strategy, including device selection, main body introduction side, and/or deployment configuration. In 4 cases, rehearsal was performed twice to achieve optimal performance. Conclusion: PsR before eEVAR was feasible in all cases and caused no time delays in the actual eEVAR procedure. PsR optimized eEVAR planning by identifying optimal strategy for stent-graft component selection and deployment.
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Aneurisma de la Aorta Abdominal/cirugía , Rotura de la Aorta/cirugía , Implantación de Prótesis Vascular , Procedimientos Endovasculares , Modelación Específica para el Paciente , Cirugía Asistida por Computador , Anciano , Anciano de 80 o más Años , Aneurisma de la Aorta Abdominal/diagnóstico por imagen , Aneurisma de la Aorta Abdominal/mortalidad , Aneurisma de la Aorta Abdominal/fisiopatología , Rotura de la Aorta/diagnóstico por imagen , Rotura de la Aorta/mortalidad , Rotura de la Aorta/fisiopatología , Prótesis Vascular , Implantación de Prótesis Vascular/efectos adversos , Implantación de Prótesis Vascular/instrumentación , Implantación de Prótesis Vascular/mortalidad , Procedimientos Endovasculares/efectos adversos , Procedimientos Endovasculares/instrumentación , Procedimientos Endovasculares/mortalidad , Estudios de Factibilidad , Femenino , Humanos , Masculino , Modelos Anatómicos , Modelos Cardiovasculares , Tempo Operativo , Complicaciones Posoperatorias/etiología , Impresión Tridimensional , Diseño de Prótesis , Factores de Riesgo , Stents , Cirugía Asistida por Computador/efectos adversos , Cirugía Asistida por Computador/instrumentación , Cirugía Asistida por Computador/mortalidad , Factores de Tiempo , Resultado del TratamientoRESUMEN
OBJECTIVE/BACKGROUND: Several abdominal aortic aneurysm (AAA) screening programs have demonstrated a similar prevalence of this disease in Westerns countries, ranging from 1.2% to 2.8%. However, the annual rate of AAA repair is significantly less even, and its relationship to AAA prevalence is not clear. The objective was to perform a systematic review, describing an international overview in the yearly rate of AAA repairs. METHODS: The number of elective and emergency AAA repairs was obtained via thorough review of publications indexed in PubMed and Scopus from 2010 to October 2018. Portuguese data were obtained from the national administrative database of health care. Data from the UK were extracted from the National Vascular Registry's 2015 annual report. Each country's population was assessed from published national censuses, thus allowing estimation of the number of AAAs treated per 100,000 habitants. RESULTS: Data from 14 countries were obtained. The yearly number of elective operations per 100,000 habitants was 2.2 in Hungary, 3.8 in Portugal, 5.3 in Spain, 5.9 in Iceland, 6.5 in Finland, 7.0 in New Zealand, 7.8 in the UK, 10.0 in Denmark, 10.2 in Sweden, 13.3 in the USA, 14.8 in Norway, 15.3 in the Netherlands, 15.6 in Italy, and 17.3 in Germany. The yearly rate of ruptured repairs was 0.5 in Hungary, 1.5 in Portugal, 1.8 in Spain, 1.7 in Iceland, 1.7 in Finland, 1.3 in New Zealand, 1.8 in the UK, 3.3 in Denmark (2013), 2.7 in Sweden (2013), 1.7 in the USA, 2.1 in Norway, 3.1 in the Netherlands, 2.3 in Italy, and 2.7 in Germany. CONCLUSION: The rate of AAA treatment is highly variable, with a nearly eightfold variance between the countries with the highest and lowest rates of elective repair. Correlation between elective and ruptured repairs was not clear. A deeper understanding of the reasons for the disparities in AAA treatment among Western countries is of the utmost importance.
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Aneurisma de la Aorta Abdominal/cirugía , Disparidades en Atención de Salud/tendencias , Pautas de la Práctica en Medicina/tendencias , Procedimientos Quirúrgicos Vasculares/tendencias , Aneurisma de la Aorta Abdominal/diagnóstico por imagen , Aneurisma de la Aorta Abdominal/epidemiología , Procedimientos Quirúrgicos Electivos/tendencias , Urgencias Médicas , Europa (Continente)/epidemiología , Humanos , Incidencia , Nueva Zelanda/epidemiología , Prevalencia , Factores de Tiempo , Estados Unidos/epidemiología , Mundo OccidentalRESUMEN
Background Optimal timing of the CT scan relative to the contrast media bolus remains a challenging task given the shorter scan durations of modern CT scanners, as well as interpatient variability. Purpose To compare contrast opacification in CT angiography of the aorta between a cohort with fixed trigger delay and a cohort with patient-specific individualized trigger delay for contrast media timing with bolus tracking. Materials and Methods In this prospective study (January-August 2018), CT angiography of the thoracoabdominal aorta with bolus tracking was performed in two different study cohorts: one with a fixed trigger delay of 4 seconds (fixed cohort) and one with a patient-specific trigger delay (individualized cohort). All CT and contrast media protocol parameters were kept identical among cohorts. Objective image quality was evaluated by one reader; two readers assessed subjective image quality. Student t test was used to test for differences in mean attenuation; the Wilcoxon-Mann-Whitney test was used to test for differences in noise, contrast-to-noise ratio, and subjective image quality. Results The fixed cohort had 108 study participants (16 women; mean age ± standard deviation, 72 years ± 10); the individualized cohort had 108 participants (16 women; mean age, 72 years ± 12). The trigger delay in the individualized cohort ranged from 6.4-11.3 seconds (mean, 9.2 seconds). There was higher overall attenuation in the individualized cohort than in the fixed cohort (486 HU ± 92 for individualized vs 438 HU ± 99 for fixed; P < .001), with increasing differences from the aortic arch (8 HU) to the iliac arteries (95 HU). The regression model indicated uniform attenuation in the individualized cohort and decreasing attenuation in the fixed cohort (decrease of 87 HU by the iliac arteries; P < .001). There was no difference between cohorts for image noise (20 vs 19; P = .41), but contrast-to-noise ratio (21 vs 19; P = .04) and subjective image quality were higher in the individualized cohort than in the fixed cohort (excellent or good image quality, 100% vs 67%; P < .001). Conclusion Compared with a fixed delay time after bolus tracking, a patient-specific individualized trigger delay improves image quality and provides uniform contrast attenuation for CT angiography of the aorta. ©RSNA, 2019.
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Aorta/diagnóstico por imagen , Angiografía por Tomografía Computarizada/métodos , Medios de Contraste/administración & dosificación , Interpretación de Imagen Radiográfica Asistida por Computador/métodos , Anciano , Anciano de 80 o más Años , Algoritmos , Aortografía/métodos , Femenino , Humanos , Yohexol/administración & dosificación , Yohexol/análogos & derivados , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Factores de TiempoRESUMEN
BACKGROUND: Intravascular ultrasound (IVUS) has been introduced as diagnostic adjunct to provide new insights into the diagnosis and therapy of vascular disease. Herein, we compared the outcomes of conventional endovascular aneurysm repair (EVAR) and EVAR with IVUS in patients presenting with infrarenal abdominal aortic aneurysm using a propensity-matched cohort. METHODS: From May 2013 to August 2017, 221 patients were retrospectively analyzed. Of that, 122 patients were eligible for inclusion and underwent propensity score matching. Perioperative mortality and morbidity, renal function impairment, endoleak incidence, mean contrast medium usage, operative time, radiation exposure (including fluoroscopy time, dose-area product [DAP], and digital subtraction angiography [DSA] runs), survival, and freedom from reintervention were the outcomes measured. RESULTS: After matching, 52 patients were included, 26 in the conventional EVAR group and 26 in the EVAR with IVUS group. No perioperative mortality or type I/III endoleak were registered. One perioperative lymphatic fistula and one iliac limb occlusion were observed. In the EVAR with IVUS group, a significant reduction of contrast medium (92 [vs. 51 ± 17] vs. 51 [20-68] mL; P = 0.003) and radiation exposure including fluoroscopy time (12 [9-16] vs. 20 [12-25] min; P = 0.001), DAP (15 [9-21] vs. 32 [16-44] G*cm2; P = 0.002), and DSA runs (2 [1-3] vs. 3 [2-4]; P = 0.04) was reported. No differences were observed in terms of glomerular filtration rate (86 [45-121] vs. 90 [38-117] mL/min; P = 0.14) and operation time (176 [124-210] vs. 179 [120-210]; P = 0.48). Survival at 36 months was 93% for standard EVAR and 92% for EVAR with IVUS (P = 0.845). Freedom from reintervention at 36 months was 85.5% in both the groups (P = 0.834). CONCLUSIONS: In this preliminary experience, the use of IVUS during EVAR was feasible with no registered postoperative complications. A significant reduction of contrast medium usage and radiation exposure was observed with the use of IVUS. The IVUS is an adjunctive tool to consider in the vascular surgeon armamentarium, especially in centers where advanced radiological tools of imaging fusion are not available.
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Aneurisma de la Aorta Abdominal/diagnóstico por imagen , Aneurisma de la Aorta Abdominal/cirugía , Implantación de Prótesis Vascular , Procedimientos Endovasculares , Ultrasonografía Intervencional , Anciano , Anciano de 80 o más Años , Angiografía de Substracción Digital , Aortografía/métodos , Implantación de Prótesis Vascular/efectos adversos , Medios de Contraste/administración & dosificación , Procedimientos Endovasculares/efectos adversos , Femenino , Humanos , Italia , Masculino , Persona de Mediana Edad , Valor Predictivo de las Pruebas , Datos Preliminares , Dosis de Radiación , Exposición a la Radiación/efectos adversos , Exposición a la Radiación/prevención & control , Estudios Retrospectivos , Factores de Riesgo , Factores de Tiempo , Resultado del TratamientoRESUMEN
INTRODUCTION: Aortic dissections classification systems have always been an argument of debate. It is well known that none of the described classifications is complete and easy at the same time. While the more used classification is currently the Stanford classification, it is clear that type A and B dissections prognosis can dramatically vary, depending on many different characteristics that they can present. The aim of this study was to propose a new severity score system that could reflect the risk of in hospital mortality of acute aortic dissections. EVIDENCE ACQUISITION: Through a review of the literature, studies describing significant predictors of in hospital mortality of any type of aortic dissection were searched and selected by predefined selection criteria. EVIDENCE SYNTHESIS: Nine studies met the criteria and were finally analyzed. The Odds Ratios of the reported predictors were the basis to the drawing of the score system. Sixteen main in hospital mortality predictors were found, 14 of which described in more than one study. They were combined into a new severity score system that we named VI2TA2 S2C2ORE. CONCLUSIONS: This is a simple risk score that we propose as a first assessment risk-evaluating tool. We look forward to validate it and to describe specific in hospital mortality risk ranges once it will be adopted.
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Aneurisma de la Aorta/clasificación , Disección Aórtica/clasificación , Disección Aórtica/mortalidad , Mortalidad Hospitalaria , Enfermedad Aguda , Aneurisma de la Aorta/mortalidad , Hospitalización , Humanos , Oportunidad Relativa , Pronóstico , Factores de Riesgo , Índice de Severidad de la EnfermedadRESUMEN
PURPOSE: To evaluate outcome of endovascular elective repair and repair of ruptured isolated iliac artery aneurysms (IIAAs) as a primary treatment strategy. MATERIALS AND METHODS: All patients with an IIAA undergoing endovascular treatment were included. Aneurysms were classified according to an anatomic classification and treated with coiling of the internal iliac artery, stent graft placement in the common to external iliac artery, or placement of a bifurcated aortoiliac stent graft. Between November 1996 and November 2015, 72 patients with 85 IIAAs underwent endovascular repair. Mean age was 73.9 years ± 9.2. Common iliac artery was involved in 63 patients (74.1%), internal iliac artery was involved in 21 patients (24.7%), and external iliac artery was involved in 1 patient (1.2%). Mean diameter was 5 cm (range, 2.5-11 cm). Emergency repair was performed in 19 patients owing to rupture (26.4%). RESULTS: Overall primary technical success rate was 95.8% with conversion rate to open surgery of 4.2% (all in the emergency group) and in-hospital mortality rate of 1.4%. During mean follow-up of 4.3 years ± 3.3 (median 3.8 y; range, 0-14.2 y), 17 endoleaks were observed (6 type I, 10 type II, 1 type IIIa). Overall reintervention rate was 16.7%. Primary patency rate was 98.6%. During the follow-up period, 22 deaths occurred (30.6%), including 2 aneurysm-related deaths (2.8%). CONCLUSIONS: Primary endovascular repair of IIAAs shows excellent results and should be considered as first-line therapy. Surgical backup should be available in emergency cases.
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Aneurisma Roto/cirugía , Implantación de Prótesis Vascular , Embolización Terapéutica , Procedimientos Endovasculares , Aneurisma Ilíaco/cirugía , Arteria Ilíaca/cirugía , Anciano , Anciano de 80 o más Años , Aneurisma Roto/diagnóstico por imagen , Aneurisma Roto/mortalidad , Aneurisma Roto/fisiopatología , Prótesis Vascular , Implantación de Prótesis Vascular/efectos adversos , Implantación de Prótesis Vascular/instrumentación , Implantación de Prótesis Vascular/mortalidad , Angiografía por Tomografía Computarizada , Conversión a Cirugía Abierta , Procedimientos Quirúrgicos Electivos , Embolización Terapéutica/efectos adversos , Embolización Terapéutica/mortalidad , Urgencias Médicas , Endofuga/mortalidad , Endofuga/cirugía , Procedimientos Endovasculares/efectos adversos , Procedimientos Endovasculares/instrumentación , Procedimientos Endovasculares/mortalidad , Femenino , Humanos , Aneurisma Ilíaco/diagnóstico por imagen , Aneurisma Ilíaco/mortalidad , Aneurisma Ilíaco/fisiopatología , Arteria Ilíaca/diagnóstico por imagen , Arteria Ilíaca/fisiopatología , Masculino , Persona de Mediana Edad , Reoperación , Estudios Retrospectivos , Stents , Factores de Tiempo , Resultado del Tratamiento , Grado de Desobstrucción VascularRESUMEN
A 59-year-old man was referred with complicated chronic type B aortic dissection. Despite the false lumen's being dominant in terms of caliber and limb perfusion, visceral arteries originated in a 9-mm true lumen. A staged approach was performed: open aortobi-iliac bypass with preservation of both lumens to the infrarenal aorta, with reinforcement of the aorta and anastomosis with Dacron (wrap technique); exclusion of the dissection by endografting all of the false lumen with three successive thoracic endoprostheses; and maintenance of true lumen perfusion using two periscopes with self-expanding nitinol stents. The patient remains asymptomatic after 1 year of follow-up.
RESUMEN
OBJECTIVE: The objective of this study was to report the 1-year follow-up study results of the new Horizon stent graft (Endospan, Herzliya, Israel) from two different prospective consecutive trials. The Horizon abdominal aortic aneurysm stent graft system is a 14F profile system requiring only a single access site. It consists of three modules, introduced separately: base limb (iliac to iliac limb); distal aortic limb; and proximal aortic limb with a bare suprarenal crown and active fixation. METHODS: Data from the first in man (FIM) clinical study with 10 patients enrolled and the pivotal study with 30 patients were analyzed. Outcomes measured were freedom from major adverse events (MAEs) including all-cause mortality, myocardial infarction, renal failure, respiratory failure, paraplegia, stroke, bowel ischemia, and procedural blood loss ≥1000 mL. Performance end points included successful delivery and deployment of the device, freedom from aneurysm growth ≥5 mm, type I or type III endoleak, stent graft occlusion, conversion to open surgery, rupture, and stent graft migration. RESULTS: In the FIM study, one conversion to open surgery with >1000 mL of blood loss was registered perioperatively. In the pivotal study, no perioperative MAE was registered. Overall, at 1-year follow-up, two deaths and one aneurysm growth unrelated to endoleak were registered. CONCLUSIONS: The results of both the FIM and pivotal studies demonstrated that 39 of 40 procedures were successful for delivery and deployment of the Horizon stent graft. No MAE was registered during the follow-up. The primary safety and performance end points were met in both studies.
Asunto(s)
Aneurisma de la Aorta Abdominal/cirugía , Implantación de Prótesis Vascular/instrumentación , Prótesis Vascular , Procedimientos Endovasculares/instrumentación , Stents , Anciano , Aneurisma de la Aorta Abdominal/diagnóstico por imagen , Aneurisma de la Aorta Abdominal/mortalidad , Aortografía/métodos , Implantación de Prótesis Vascular/efectos adversos , Implantación de Prótesis Vascular/mortalidad , Procedimientos Endovasculares/efectos adversos , Procedimientos Endovasculares/mortalidad , Europa (Continente) , Femenino , Humanos , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/etiología , Estudios Prospectivos , Diseño de Prótesis , Factores de Tiempo , Tomografía Computarizada por Rayos X , Resultado del TratamientoRESUMEN
BACKGROUND: The aim of this study was to evaluate the technical success of percutaneous ultrasound-guided access to the infraclavicular axillary artery with a suture-mediated closing device for patients requiring large-sized upper extremity access. PATIENTS AND METHODS: In 18 consecutive patients (17 male, one female, mean age 73.5 ± 9.6 years, range 52-88 years), artery accesses with the preclosing modification for chimney endografts was gained with 20 ultrasound-guided infraclavicular axillary. Retrospectively, the following endpoints were analysed: technical success of percutaneous ultrasound-guided puncture of the infraclavicular axillary artery as well as introduction and deployment, primary successful haemostasis by preclosing, bailout procedures, overall complication rate including local vascular, cerebrovascular, and peripheral neurological complications. RESULTS: Ultrasound-guided puncture and preclosing procedure was successful in all patients. Mean sheath size was 9.4 ± 1.6 French. Ultrasound-guided puncture as well as introduction and deployment were successful in all patients (100 %). Primary successful haemostasis by preclosing was 70 % (14/20). Postclosing with one or two devices enabled successful haemostasis in another 15 %. Bailout stent graft implantation was necessary in three accesses (15 %), either by transfemoral (n = 2) or transbrachial (n = 1) route. Overall complication rate was 16.5 %, all of them were minor haematomas. CONCLUSIONS: Percutaneous ultrasound-guided infraclavicular axillary artery access with preclosing modification seems feasible and safe. The access related complication rate is low and complications can potentially be managed by endovascular means.
Asunto(s)
Aneurisma de la Aorta Torácica/cirugía , Arteria Axilar , Pérdida de Sangre Quirúrgica/prevención & control , Implantación de Prótesis Vascular/instrumentación , Prótesis Vascular , Cateterismo Periférico , Procedimientos Endovasculares/instrumentación , Técnicas Hemostáticas/instrumentación , Hemorragia Posoperatoria/prevención & control , Técnicas de Sutura , Dispositivos de Cierre Vascular , Anciano , Anciano de 80 o más Años , Angiografía de Substracción Digital , Aneurisma de la Aorta Torácica/diagnóstico por imagen , Arteria Axilar/diagnóstico por imagen , Implantación de Prótesis Vascular/efectos adversos , Cateterismo Periférico/efectos adversos , Procedimientos Endovasculares/efectos adversos , Femenino , Técnicas Hemostáticas/efectos adversos , Humanos , Masculino , Persona de Mediana Edad , Proyectos Piloto , Hemorragia Posoperatoria/etiología , Diseño de Prótesis , Punciones , Estudios Retrospectivos , Factores de Riesgo , Resultado del Tratamiento , Ultrasonografía IntervencionalRESUMEN
OBJECTIVE: A new endovascular tool, the Liungman Guidewire Fixator, has been developed to simplify endovascular treatment in complex aortic aneurysms. The device has been extensively tested in bench models and animal trials. To verify the safety and functionality demonstrated in the porcine model, the device was tested in ten patients undergoing endovascular aortic repair (EVAR) or fenestrated endovascular aortic repair (f-EVAR) treatment for abdominal aortic aneurysm. METHODS: The Liungman Guidewire Fixator consists of a braided stent-like, cylindrical structure with conical ends and a central channel for a 0.035â³ guidewire. When in use, it is slid along the guidewire and positioned in the target artery, where the Liungman Guidewire Fixator interacts with the arterial wall by anchoring the guidewire to the wall through a radial force. The Liungman Guidewire Fixator allows for uninterrupted blood flow passed the point of fixation. In this study, the Liungman Guidewire Fixator was tested in ten patients undergoing EVAR or f-EVAR treatment for abdominal aortic aneurysm. The device was deployed and retrieved crossover into the hypogastric artery, and the occurrence of thrombotic occlusion, arterial dissection, and vascular rupture or trauma was studied using angiography, as well as device ability to withstand guidewire tension. RESULTS: There were no instances of occlusion, dissection, or vascular trauma detected using angiography. In all cases, deployment and retrieval were successful, and the devices could withstand an applied tension of 3 N. In one instance, retrieval was challenging because of significant tortuosity, which was resolved by a coaxial catheterization. CONCLUSIONS: Deployment was uneventful in all ten patients. Retrieval according to the intended instruction for use was performed in nine of the patients. In one patient, a coaxial catheterization was necessary. All devices withstood a retention force of 3 N.