Editor's Choice - Outcomes of Self Expanding PTFE Covered Stent Versus Bare Metal Stent for Chronic Iliac Artery Occlusion in Matched Cohorts Using Propensity Score Modelling.

OBJECTIVES: The aim was to compare outcomes of self expanding PTFE covered stents (CSs) with bare metal stents (BMSs) in the treatment of iliac artery occlusions (IAOs). METHODS: Between January 2009 and December 2015, 128 iliac arteries were stented for IAO. A CS was implanted in 78 iliac arteries (61%) and a BMS in 50 (49%). After propensity score matching, 94 limbs were selected and underwent stenting (47 for each group). Thirty day outcomes and midterm patency were compared; follow-up results were analysed with Kaplan-Meier curves. RESULTS: Overall, iliac lesions were classified by limb as TASC B (19%), C (21%), and D (60%). Technical success was 98%. Comparing CS versus BMS, the early cumulative surgical complication rate (12% vs. 12%, p = 1.0) and 30 day mortality rate (2% vs. 2%, p = 1.0) were equivalent. At 36 months (average 23 ± 17), overall primary patency was similar between CS and BMS (87% vs. 66%, p = .06), and this finding was maintained after stratification by TASC B (p = .29) and C (p = .27), but for TASC D, CSs demonstrated a higher patency rate (CS, 88% vs. BMS, 54%; p = .03). In particular, patency was in favour of CSs for IAOs > 3.5 cm in length (p = .04), total lesion length > 6 cm (p = .04), and IAO with calcification > 75% of the arterial wall circumference (p = .01). CONCLUSIONS: Overall, the use of self expanding CS for IAOs has similar early and midterm outcomes compared with BMS. Even if further confirmatory studies are needed, CSs seem to have higher midterm patency rates than BMSs for TASC D lesions, IAOs with a total lesion length > 6 cm, occlusion length > 3.5 cm, and calcification involving > 75% of the arterial wall circumference. These specific anatomical parameters may be useful to the operator when deciding between CS and BMS during endovascular planning.

Parallel endografts in the treatment of distal aortic and common iliac aneurysms.

OBJECTIVES: Endovascular treatment of distal abdominal aortic aneurysms (D-AAA) and bilateral common iliac artery aneurysms (BCIAA) may present technical challenges for standard EVAR. Parallel iliac leg endografts (ILEs) of standard aortic devices and covered stents have been successfully employed to treat patients with D-AAA and BCIAA. The perioperative and long-term results of this straightforward endovascular technique are presented. METHODS: Beginning in 2009, patients deemed unfit for open surgery underwent parallel endografts D-AAA and BCIAA exclusion. Avoiding the use of a main body, ILEs are simultaneously delivered from both femoral arteries, landing parallel into the aortic neck (parallel grafts: PG). Distal landing zones including external iliac arteries (EIAs) are reached using appropriate ILEs. A third parallel covered stent graft (Viabahn, Gore) is delivered from a left brachial approach to maintain prograde blood flow to one internal iliac artery (IIA) when needed. RESULTS: Eighteen patients were successfully treated using parallel endografts, nine for BCIAA and nine for D-AAA. All D-AAA presented an irregular saccular shape, including three penetrating aortic ulcers and two pseudoaneurysms of previous aortic grafts. Prograde flow to one IIA was successfully maintained using a Viabahn graft in five patients with BCIAA. Mean aneurysm size was 50 mm in D-AAA and 43 mm in BCIAA. One patient required a perioperative ILE extension to treat a type Ib endoleak. One patient suffered a minor stroke 24 hours after the procedure. Two type II endoleaks were observed postoperatively. Five patients died of non-aneurysm related causes during follow-up. No new endoleaks, graft displacements or occlusions were observed during follow-up (median: 26 months, range 12-42 months). CONCLUSIONS: Successful exclusion of D-AAA and BCIAA was achieved in high-risk patients using parallel endografts, allowing antegrade blood flow to one IIA when needed. Commercially available endografts were used in a simple and effective approach, with excellent follow-up results.

The "open" chimney graft technique for juxtarenal aortic aneurysms with discrepant renal arteries.

OBJECTIVES: A straightforward original Chimney Graft (CG) protocol has been developed at our institution in selected cases of juxtarenal aortic aneurysm (JRAA). The aim of this study was to present our clinical experience of consecutive series with use of uncovered self-expanding stent (SES) as "Open Chimney" (OCh) in the endovascular repair (EVAR) of JRAA. METHODS: A standard endograft with suprarenal fixation struts is delivered with its proximal covered edge just below the highest RA in JRAA presenting the ostium of the two renal arteries at a different aortic level and the distance between the highest renal artery and the beginning of the aneurysm (improved landing zone) ≥10 mm. The low-lying renal artery is maintained patent by the OCh graft (standard SES) delivered from left brachial access (6 Fr). All clinical, anatomical, and operative data were prospectively collected and retrieved for the study analysis. RESULTS: From July 2010 to November 2012, OCh EVAR was offered to 22 consecutive patients considered unfit for JRAA open repair. All procedures were technically successful with aneurysm exclusion and patent OCh graft. One small perioperative type Ia endoleak spontaneously disappeared at the 3-month CT control. One patient died because of acute decompensated heart failure. One patient presented a left hemispheric stroke. The median follow-up of 18 months (range 7-35) showed aneurysm exclusion in all patients without type I and III endoleaks, SES stenosis, and/or renal impairment. CONCLUSIONS: OCh-EVAR is a straightforward technique that can be employed in selected cases of JRAA, avoiding the more complex and expensive fenestrated EVAR.

Open repair for ruptured abdominal aortic aneurysm: is it possible to predict survival?

The aim of the study was to determine variables that could be used to predict survival in patients with ruptured abdominal aortic aneurysm (RAAA) and to assess the accuracy of the Glasgow Aneurysm Score (GAS) and the Acute Physiology Chronic Health Evaluation II (APACHE-II). From January 1998 to July 2006, 103 patients underwent operations for RAAA. For each patient, 44 variables were retrospectively recorded in a database. Data were analyzed with univariate and multivariate methods. In the univariate analysis significant predictors of death were hypotension (p=0.001), preexisting peripheral vascular disease (p<0.001), renal insufficiency (p=0.037), chronic obstructive pulmonary disease (p=0.028), level of HCO(3)(-) (p<0.001), intraperitoneal rupture (p=0.001), blood transfused (p<0.001), cardiac complications (p<0.001), and APACHE-II score (p=0.001). Multivariate analysis confirmed statistical significance for coexisting peripheral vascular disease (p<0.001), diastolic blood pressure at admission <60 mm Hg (p=0.039), APACHE-II score >18.5 (p=0.025), HCO(3)(-) <21 mg/dL (p<0.001), and intraperitoneal rupture of the aneurysm (p=0.011) as predictors of death. Results of the study suggested that different factors can be helpful in identifying those patients whose operative risk is prohibitive. APACHE-II, contrary to GAS, is an accurate system to predict postoperative death after repair for RAAA.

Endovascular treatment of asymptomatic popliteal aneurysms: 8-year concurrent comparison with open repair.

AIM: The aim of this prospective comparative study was to compare the results of 8-years experience of endovascular treatment (ET) of popliteal aneurysms (PAs) using the Hemobahn/Viabahn endograft with those achieved with open repair (OR). Endpoints were primary and secondary patency rate. METHODS: The study was a prospective randomized clinical trial from January 1999 to December 2003 and a prospective comparative study from January 2004 to December 2006. Patients with an asymptomatic aneurismal lesion in the popliteal artery 2 cm at angio-computed tomography were included in the study. Indication for ET was PA (proximal and distal neck length >1 cm); contraindications were: 1) age <50 years; 2) poor distal run-off; 3) contraindication to antiplatelet, anticoagulant or thrombolytic therapy. RESULTS: Between January 1999 and December 2006, of a total of 42 patients with 48 PA, 27 were treated with OR (group A) and 21 with ET (group B). The primary patency rate was 100% in group A and 80.9% in group B at 12 months and 71.4% and 88.1%, respectively, at 72 months; the secondary patency rate at 72 months was 88.15% and 85.9% in groups A and B, respectively. No statistical differences were observed at the log-rank test. During the entire study period, 3 (14.3%) patients in group B required conversion to open surgery because of endograft occlusion. CONCLUSION: Within the power limitations of this study, ET for asymptomatic PA in patients with suitable anatomy can be considered safe, with long-term results comparable with those of OR.

Glasgow aneurysm score predicts the outcome after emergency open repair of symptomatic, unruptured abdominal aortic aneurysms.

OBJECTIVE: To determine the predictor factors of in-hospital postoperative mortality in patients presenting with symptomatic but not ruptured abdominal aortic aneurysm (AAA) at our institution. PATIENTS AND METHODS: Forty-two patients who underwent urgent open repair for symptomatic, non-ruptured AAA were evaluated retrospectively. RESULTS: Five patients (11.9%) died during the in-hospital stay. History of coronary artery disease (p=0.014), cerebrovascular diseases (p=0.015), renal failure according to Glasgow Aneurysm Score (GAS) criteria (p=0.001), serum creatinine concentration (p=0.026), and the GAS (p=0.008) were predictive of postoperative death. The ROC curve analysis showed that the Glasgow Aneurysm Score had an area under the curve of 0.870 (95%C.I. 0.71-1, S.E. 0.08, p=0.008), and its best cut-off value in predicting postoperative death was 90.0 (specificity 89.2%, sensitivity 80.0%). The postoperative mortality rate of patients with a Glasgow Aneurysm Score below 90 was 2.9%, whereas it was 50% for those with a score >or=90 (p=0.003, O.R. 33.0). CONCLUSION: This study shows that the Glasgow Aneurysm Score is a good predictor of postoperative mortality and morbidity after urgent repair of symptomatic, non-ruptured AAA and can be useful in identifying those patients whose operative risk is prohibitive. Its simplicity makes it a clinically important tool, particularly, in the emergency setting. Patients having a score less than 90 can safely undergo urgent open repair. Thorough evaluation and improvement of preoperative status followed preferably by an endovascular repair is indicated for those with a score >or=90.

Hyaluronan biodegradable scaffold for small-caliber artery grafting: preliminary results in an animal model.

OBJECTIVE: To evaluate a new Hyaluronan-based graft. MATERIAL AND METHODS: Hyaluronan-based grafts (HYAFF 11trade mark tube, diameter 2 mm, length 1.5 cm) were implanted in an end-to-end fashion in the abdominal aorta of 15 rats. Histology, immunohistochemistry and electron microscopy were used to evaluate the results at 7, 21, and 90 days. RESULTS: At day 7, new tissue was observed in the graft coming from both the proximal and distal ends of the aorta. The luminal surface of the regenerating tissue was covered by endothelial cells (CD34(+), VEGFR-2(+), vWF(+)). At day 21, regenerating tissue joined at the centre of the tube. The neo-vessel was formed by smooth muscle cells (Myosin Light Chain Kinase) as well as elastic, and collagen fibres. At day 90 a stable artery segment was formed and the biomaterial was almost completely degraded. Infiltration of neutrophils and lymphocytes was not observed. All animals survived the observation period and there were no signs of stenoses or aneurysms. CONCLUSION: The hyaluronan-based graft allowed complete regeneration of a newly formed vascular tube in which all the cellular and extracellular components are present and organized in a well defined architecture similar to native artery.

Is carotid endarterectomy in octogenarians more dangerous than in younger patients?

AIM: The risk for developing stroke increases with the advancing age, peaking over age 80. In elderly patients, carotid endarterectomy may provide prophylaxis against stroke. Aim of our study was to compare patients 80 years or older with patients younger than 80 undergoing carotid endarterectomy. Endpoints were perioperative mortality and morbidity. METHODS: From January 1996 to December 2002, 1 659 patients underwent a 1 733 carotid endarterectomy for a symptomatic or asymptomatic significant carotid lesion. Among them, 125 patients were 80 years or older. We analyzed death and stroke rate from cerebrovascular accidents, TIA as well as non cerebrovascular complications and death rate postoperatively and in the long term follow-up. The Pearson's chi-squared(2) test was used for the statistical analysis on risk factors, morbidity and mortality. The Log rank test was used for cumulative stroke-free and survival rates between the 2 groups (level of confidence p<0.05). RESULTS: Risk factors were similar in both groups. No statistical difference was observed in the stroke, TIA, mortality and stroke free rates between the 2 groups. CONCLUSIONS: The results of our study show that perioperative and postoperative mortality and morbidity as well as the long-term stroke-free rate does not differ significantly in patients 80 years or older compared to patients younger than 80 undergoing carotid endarterectomy.

Synchronous carotid endarterectomy and retrograde endovascular treatment of brachiocephalic or common carotid artery stenosis.

OBJECTIVES: To retrospectively evaluate the safety and the long-term results of retrograde brachiocephalic and common carotid angioplasty and stenting (AS) performed for >70% stenosis synchronously with the carotid endarterectomy (CEA). PATIENTS: Sixteen patients operated between April 1999 and March 2002. RESULTS: 14/16 procedures were successful. There was no neurological morbidity or mortality. Per-operative angiography showed the optimal stent positioning and patency of both proximal and distal arteries in all patients. In the follow-up, all patients showed patency of the treated vessels without restenosis and the absence of any cerebrovascular symptoms. CONCLUSION: Intra-operative retrograde AS combined with CEA is an effective, safe and durable alternative to conventional surgery when a tandem significant proximal lesion is identified in a patient with an high grade carotid stenosis.

Rationale of the surgical treatment of carotid kinking.

AIM: Elongation and tortuosity of the internal carotid artery (ICAET) is a common angiographic, angioMR or Duplex scanning finding: it can be "pure" and, in a great majority of cases, it is not correlated to neurological symptoms. It can be associated with atherosclerotic bifurcation plaque, therefore in this case, indications to surgery follow that of carotid stenosis. On the other hand in some patients ICAET seems potentially correlated to hemispheric or non hemispheric symptoms: ICAET may show as kinking with a wide or narrow acute angle, single (< shaped) or double (Z shaped), or less frequently as a coiling (S,U, or C shaped). Surgical indications are controversial. In the author's opinion, surgery may represent the safest tool in the prevention of a stroke due to carotid occlusion, in selected patients. The aim of this study is to describe the author's experience in the surgical treatment of carotid kinking not associated with significant atherosclerotic lesions. METHODS: From March 1994 to March 2001, 29 patients (11 male, 18 female) with a pure ICAET underwent surgery. Patients presented hemispheric symptoms (24.13%), non hemispheric symptoms (41.3%) or both (27.5 %). Two asymptomatic patients (6.9%) underwent surgery because of contralateral carotid occlusion. RESULTS: The postoperative (within 30 days from operation) results, no mortality was observed, 1 patient presented a stroke (3.4%), and 1 patient had a TIA at awakening (negative cerebral CT scan). All patients with hemispheric symptoms (15 patients) had complete remission, whereas only 6 out of 12 patients (50%) presenting non-hemispheric symptoms had remission (1 patient underwent a controlateral ICAET correction). CONCLUSIONS: The natural history of symptomatic and asymptomatic ICAET is practically unknown, but in some cases selected indication to surgery is justified. Surgery was indicated for patients with transient ischaemic attacks ( hemispheric symptoms); in asymptomatic patients presenting a kinking with an angle inferior to 30 degrees, and a contralateral carotid artery occlusion; in patients with non hemispheric symptoms, after a screening to exclude all other possible neurological or non-neurological causes with duplex scan positive for significant increase of flow velocity in ICA and positive cerebral CT scan or MR scan for ischaemic lesions in the homolateral hemisphere, and/or a flow inversion in anterior cerebral artery or flow reduction in the middle cerebral artery, according to different head positions (rotation and flex-extension).

Visceral artery aneurysms: a single center experience.

BACKGROUND: Splanchnic artery areurysm is a rare but clinically relevant disease, showing a high mortality rate in emergency surgery. Reports on splanchnic aneurysms are rare and often anecdotal. The aim of this study is to discuss data obtained from 16 patients in a single vascular surgery center. MATERIALS AND METHODS: Between January 1987 and December 2000, 16 patients underwent surgery for splanchnic artery aneurysms. In 13 patients the localization was single (in two associated with an infrarenal abdominal aortic aneurysm) and in 3 patients multiple. The arteries involved were: splenic (8), hepatic (4), celiac (3), superior mesenteric (3), ileocolic (2), and pancreatoduodenal (1). 13 patients were asymptomatic and 3 presentec with abdominal pain. All patients underwent CT scan, and abdominal aortic and selective visceral artery angiography. Before surgery, all patients underwent cerebral MR or cerebral CT scan. 13 patients underwent open vascular surgery; 3 patients (2 splenic and 1 hepatic) underwent endovascular procedure (angioembolization). Histological examination of the aneurysmal wall was obtained in 14 patients. Ultrasound examination was performed after 6 months, then yearly. 14 patients underwent abdominal CT scan during the long-term follow-up. RESULTS: Perioperative mortality was absent. 12 cases were classified as displastic, with minor or major secondary atherosclerotic changes, and in many cases severe calcications. 2 cases were classified as atherosclerotic. Cerebral MR did not show any cases of intracerebral displastric aneurismal disease. One patient was lost at follow-up after 9 years. One patient showed a recurrence at 6 years (superior mesenteric artery): the patient underwent a new surgical procedure and died 20 days after surgery for intestinal infarction. All abdominal follow-up CT scans show good results of the vascular reconstruction and escluded other new visceral or aortic aneurysms. CONCLUSIONS: Visceral artery aneurysms are an uncommon form of abdominal vascular disease showing a high postoperative mortality rate in emergencies. Surgery, and in selected cases, endovascular treatment, can successfully manage splanchnic artery aneurysms with few complications and low recurrence.

Prospective comparative study of two cerebral protection devices in carotid angioplasty and stenting.

BACKGROUND: The aim of the study was to compare two of the available cerebral protection devices (CPD) PercuSurge, balloon type (group A) and Angioguard, filter type (group B) used in carotid stenting and angioplasty (CAS). METHODS: From September 1999 to February 2001, 26 consecutive patients undergoing CAS were alternatively assigned to group A and B. Postoperative disabling stroke and neurological mortality, nondisabling stroke, TIA and non-neurological mortality were examined. CPD features included time required, ease of handling, device rupture or malfunctioning, radiopaque markers evidence, abnormal major mobility of the opened system. RESULTS: RNCR was 0 and TIAs were not observed in either group. Four patients (3 in group A and 1 in group B) showed drowsiness in the immediate postoperative period. Perioperative carotid occlusion and surgical conversion were observed in 1 case of group A. Average time calculated from the beginning of set-up to complete removal was 46 min in group A versus 31 min in group B. Abnormal major mobility of the opened system was very often observed during endovascular maneuvers with both devices. CONCLUSIONS: CAS may protect against postoperative procedure-related neurological events. Common and specific disadvantages were observed in both systems showing they were not close enough to the ideal device.

MMP9 production by human monocyte-derived macrophages is decreased on polymerized type I collagen.

The production of matrix metalloproteinases (MMPs), such as MMP9, by macrophages may be a critical factor in the rupture of unstable atherosclerotic plaques and aortic aneurysms. Therefore, we studied the role of matrix and soluble cytokines in the regulation of monocyte/macrophage expression of MMP9. Although freshly isolated monocytes synthesize little MMP9, cells cultured on tissue-culture plastic differentiate into macrophages and synthesize maximal amounts of MMP9. Differentiated macrophages cultured on plastic are unresponsive to further stimulation by interleukin 1beta, tumor necrosis factor alpha, or platelet-derived growth factor BB. In contrast, monocytes cultured on polymerized collagen synthesize much less MMP9 than cells cultured on plastic and demonstrate a more than three-fold increase in MMP9 synthesis in response to interleukin 1beta, tumor necrosis factor alpha, and platelet-derived growth factor BB. To determine whether the physical state of the collagen was critical for the decrease in basal synthesis of MMP9, monocytes were cultured in suspension for 5 days to allow differentiation and then seeded onto monomer or polymerized collagen. Synthesis of MMP9 was significantly decreased in cells on polymerized collagen and modestly increased in macrophages seeded on monomer collagen. These results suggest that MMP9 synthesis by macrophages in the vessel wall may be under negative control by native, polymerized collagen and that disruption of this native conformation could increase MMP9 production. In addition, cells in contact with the collagen matrix are potentially more responsive to soluble mediators such as platelet-derived growth factor, interleukin 1beta, and tumor necrosis factor alpha.

Short-term arterial blood reperfusion of normothermic kidney in renal artery and abdominal aorta reconstructive surgery.

OBJECTIVE: to prevent kidney injury in renal artery and juxta-renal aortic surgery. After 30 min of cross-clamping ischaemia, renal arterial inflow is temporary re-established for 3 min. The aim of the study was to retrospectively analyse the results of this original technique. METHODS: between January 1987 and May 1999, 48 patients underwent kidney short-term arterial blood reperfusion, directly or through the Pruitt-Inahara shunt. The reperfusion was repeated every 30 min of ischaemia, whenever necessary. Fifty control patients underwent <30 min of kidney ischaemia. Patients were assessed by serum creatinine, digital angiography and radioisotope renography using technecium(99). RESULTS: in the study group one patient developed an acute renal failure and died (2% (-95% CI: 0-11%)). In both study and control groups patients showed a similar and moderate but temporary decline in renal function, which returned to preoperative levels after 1 week. CONCLUSIONS: the results of this study indicate that kidney short-term reperfusion may protect renal tissue from prolonged cross-clamping ischaemia (up to 100 min), also in patients considered at high risk for acute renal failure.

Carotid endarterectomy without angiography: a prospective randomised pilot study.

OBJECTIVES: to determine whether duplex ultrasonography alone is an adequate examination prior to carotid endarterectomy. DESIGN: prospective, randomised, single centre study. MATERIAL AND METHODS: all patients with carotid bifurcation stenosis greater than 70% - based on duplex scanning - were randomised to arteriography followed by carotid surgery (Group A n=96) or carotid surgery alone (Group B n=90). Study endpoints were neurological complications or death occurring between the day of randomisation and until 30 days after surgery. RESULTS: major neurological complications of death in 1 (1%) vs 3 (3.3%) patients in group A and B, respectively (n.s.). Minor neurological complications (only TIA) were observed in 0 and 3 (3.3%) patients, respectively. CONCLUSIONS: complication rates were low in both groups and within the generally accepted rate after carotid surgery in asymptomatic and symptomatic patients.