Duplex ultrasound versus CT angiography for the treatment planning of lower-limb arterial disease.

PURPOSE: This study aimed to assess the diagnostic accuracy of duplex sonography (DUS) compared with that of computed tomography angiography (CTA) in detecting occlusion and stenosis in peripheral arterial disease (PAD) in candidate patients for endovascular revascularization with intraprocedural digital subtraction angiography (DSA). METHODS: The study involved 94 patients suffering from PAD who were candidates for endovascular procedures requiring DSA. They were all submitted preoperatively to DUS and CTA. Based on image analysis, five segments of the arterial tree were assessed: iliac, common femoral, superficial femoral, popliteal, and infrageniculate. According to the stenosis or occlusion degree, the arteries were rated as nonstenotic, stenotic, and occluded. RESULTS: The agreement between DUS and CTA findings using DSA as a reference modality was expressed as a Cohen's kappa (κ) statistic agreement. Our results show that DUS has been less accurate than CTA in evaluating iliac arterial diseases (Cohen's κ agreement of 0.91 and 1.0, respectively) when measured against DSA. We found good diagnostic concordance between DUS and DSA in detecting hemodynamic stenosis and occlusion of the femoro-popliteal axis (Cohen's κ agreement between 0.96 and 0.93). Below the knee, CTA showed even less concordance with DSA (Cohen's κ 0.75). CONCLUSIONS: Because of its accuracy, high-quality DUS performed by well-trained operators may therefore represent a good alternative to CTA in patients undergoing endovascular revascularization to minimize the use of contrast-enhanced radiological imaging. Nevertheless, preoperative CTA imaging is required in cases of nondiagnostic DUS or when a more complete overview of the vascular tree is needed for complex invasive interventions.

Open Conversion for Recurrent Endograft Occlusion after Endovascular Treatment of Blunt Traumatic Aortic Injury: A Peculiar Case Report.

BACKGROUND: We report a rare case of delayed, symptomatic thoracic endograft thrombosis after the initial thoracic endovascular aortic repair (TEVAR) for blunt thoracic aortic injury which was successfully retreated with a redo TEVAR, followed by open conversion due to recurrent partial occlusion of the distal edge of the endografts. METHODS: Two years ago, a 22-year-old man had undergone an emergency TEVAR for blunt thoracic aortic injury. A Zenith Cook 22 × 100 mm (Cook Incorporated, Bloomington, IN) endograft was used. Six months later, he underwent an emergency endovascular relining of the endograft using the same type of device. The multiorgan perfusion was completely restored except for the spinal cord injury. After 8 months, a recurrent partial occlusion of the distal edge of the second graft was documented. The thoracic aorta was replaced with a 22-mm silver-coated graft (Maquet Spain, SLU). RESULTS: Histology examination showed a neointimal formation and thickening and fibrosis of the inner 1/3 of the media with loss of smooth muscle cells and increase of the elastic fibers. CONCLUSIONS: The need for secondary interventions or open conversion because of potential complications after TEVAR for traumatic aortic injury is an additional consideration when weighing the risks and benefits of endovascular repair and subsequent surveillance strategies.

Early and mid-term outcomes of a novel Endovascular Aneurysm Sealing (EVAS) system in patients with infrarenal abdominal aortic aneurysms.

BACKGROUND: Endovascular aneurysm sealing (EVAS) using the Nellix system is a promising technology for Abdominal Aortic Aneurysm (AAA) treatment. Long-term data is unavailable regarding the potential modifications of the EndoBags and their content, and the polymer behavior over time. We present our initial clinical experience with this sac anchoring endoprosthesis in 24 patients with a maximum 12 months follow-up. METHODS: From December 2013 to March 2015, 24 patients with an infrarenal AAA were treated with the Nellix™ System. Computed tomography angiography (CTA) scan control was performed at 30 days, and follow-up magnetic resonance angiography (MRA) and ultrasounds were performed at 30 days, 6 and 12 months. Median and peak systolic velocities in the suprarenal aorta were measured preoperatively and during follow-up using phase contrast sequences and Argus (Siemens, Erlangen, Germany) software of the MRA. RESULTS: We achieved 100% technical success, 0% aneurysm-related mortality and 0% endoleaks. One patient (4%) experienced early acute thrombosis of a single Nellix stent, successfully treated with thrombolysis. Sac shrinkage occurred in 80% of cases with 12-months follow-up. CONCLUSIONS: Our preliminary clinical experience is promising, with 100% early technical success and satisfactory sealing of the aneurysm sac. Postprocedural controls during 1-year follow-up revealed no morphologic changes of the aneurysm wall, stable device and endobag position, and gradual dissolution of the air initially trapped within the EndoBags. Aneurysmal sac shrinkage occurs and probably is due to the remodeling of the thrombus around the EndoBags and the dissipation of the air bubbles into the EndoBags.

One-Year Outcomes after Ruptured Abdominal Aortic Aneurysms Repair: Is Endovascular Aortic Repair the Best Choice? A Single-Center Experience.

BACKGROUND: Treatment of ruptured abdominal aortic aneurysms (rAAAs) is still burdened by high morbidity and mortality. Although endovascular aortic repair (EVAR) offers encouraging results in elective setting, its role as first-line strategy to treat rAAA is still debated. Our aim was to compare early and late outcomes in patients undergoing open surgical repair (OSR) versus EVAR for rAAAs. METHODS: A retrospective review of data extracted from medical records identified 105 consecutive patients with rAAA who were submitted to open or endovascular repairs from 2008 to 2016. The primary end point was to assess the rAAA-related mortality in the immediate postoperative period, within 1 month and 1 year after OSR, and EVAR; secondary endpoints included the following: length of stay, AAA-related postoperative complications such as acute limb ischemia, myocardial infarction, renal and respiratory failure, and rAAA-related re-interventions. Statistical analysis was performed using the Fisher exact test, χ2 test, and logistic regression calculations. Early and midterm survival rates were assessed with Cox model. RESULTS: Of the 105 patients with rAAA, 70.48% underwent OSR including 41.89% which was hemodynamically (Hd) unstable and the remaining 29.52% was submitted to rEVAR. (all Hd stable). Compared with EVAR group, the OSR group had a higher rAAA-related mortality rate for both Hd stable and Hd unstable patients: 18.92% vs. 6.45% at 24 hr; (P = 0.185) 39.19% vs. 19.35% at 30 days (P = 0.082); 44.59% vs. 38.71% at 1 year (P = 0.734) If only Hd stable patients were considered, mortality following OSR and EVAR was as follows: 6.98% vs. 6.45% at 24 hr (P = 0.703); 27.91% vs. 19.35% at 30 days (P = 0.567); 32.56% vs. 38.71% at 1 year (P = 0.764). Mean length of stay for patients was 15 days after OSR and 10 days after rEVAR (P = 0.002). At 1-year follow-up, the overall rAAA-related complications incidence was higher in the rEVAR group than that in the OSR group (47.85% vs. 18.33%; P = 0.008); re-interventions were 18.33% in OSR group vs. 21.82% in EVAR group (P = 0.917). Cox model showed that instability and coronary artery disease were predictors of overall mortality of rAAAs. CONCLUSIONS: EVAR does not independently reduce 1-year mortality in comparison with OSR in Hd stable patients. Urgent EVAR for rAAAs in unstable patients can be limited by logistical problems. It follows that patients selected for OSR have a more complex aortic anatomy and worse Hd status than those submitted to rEVAR. rEVAR burdened by a higher incidence of procedure-related complications than OSR. Reconfiguration of acute aortic services and establishment of standardized institutional protocols might be advisable for improvements in the management of ruptured AAA. A careful evaluation of whether the benefits of an endovascular strategy translate into long term benefit is needed before definitive conclusions can be drawn about the advantages of EVAR as first-line strategy for ruptured aneurysms.

Hypertension, Acute Stent Thrombosis, and Paraplegia 6 Months after Thoracic Endovascular Aortic Repair for Blunt Thoracic Aortic Injury in a 22-Year-Old Patient.

Thoracic endovascular aortic repair (TEVAR) is a less invasive option for managing traumatic injuries of the descending aorta in polytraumatized patients. Concerns arise when treating young patients with TEVAR. A 22-year-old male was admitted to the emergency department following a high-impact road traffic collision. Whole-body computed tomography (CT) scan documented multiple injuries, including rupture of descending thoracic aorta just below the isthmus. There was no evidence of paraplegia or stroke. We decided to treat him in an endovascular fashion with a Zenith Cook (Cook Incorporated, Bloomington, IN) endograft. Final angiography confirmed the proper positioning of the device, no infoldings, and the optimal filling of the thoracic aorta downstream of the endoprosthesis. In the postoperative period, the patient showed high blood pressure which was treated with 4 different antihypertensive drugs. He was discharged on cardioaspirine. CT scan control was scheduled after 30 days and 6 months, but he referred to our emergency department after less than 6 months with paraplegia, abdominal pain, and acute renal failure. He had independently discontinued antiplatelet therapy 3 months before. Emergency CT control documented the presence of intimal flap and thrombus at the distal edge of the device. The magnetic resonance imaging revealed ischemic damage of the spinal cord. We decided to reline the endograft using another Zenith Cook device with very good results. Renal failure and bowel pain gradually improved, but paraplegia is still present. TEVAR is the most suitable treatment for blunt thoracic aortic injury in the modern era. Concerns arise from what can happen to a young aorta receiving a stiff endovascular graft that should be carried all lifelong. These devices have been associated with acute hypertension and cardiac remodeling. Less stiffer stent grafts should be studied for young patients. High attention must be posed in the follow-up for the immediate resolution of eventual problems.

Therapeutical Options in the Management of Carotid Dissection.

BACKGROUND: The best management of carotid artery dissection (CAD) is still controversial ranging from antiplatelet medication to open surgery or endovascular treatment. In this retrospective study, we assessed the safety and efficacy of endovascular stent angioplasty for the treatment of CAD. METHODS: From February 2006 to February 2016, 44 patients (28 women and 16 men, age range 25-65 years, mean 42) with CAD were included in this study. The internal carotid artery dissection was spontaneous in 32 patients and posttraumatic in the remaining 12 (in 1 case, it was bilateral). Twenty-eight patients were treated by intravenous heparin infusion followed by standard oral anticoagulation. Carotid artery stenting was carried out in 14 cases with recurrent ischemic events despite optimal anticoagulation management. Two patients with an open trauma of the neck were submitted to a common carotid to internal carotid bypass (CC-CI bypass). The follow-up ranged from 6 to 60 months and was performed clinically first and with Doppler ultrasound and computed tomography or magnetic resonance at 6, 12, and 24 months. RESULTS: Follow-up ranged from 6 to 60 months. Mortality was nil. All patients submitted to the endovascular or surgical management had an immediate relief of their neurologic symptoms with no procedure-related complications. No thrombosis or restenosis of the CC-CI bypass or of carotid artery stents occurred during intraoperative and postoperative period and follow-up. CONCLUSION: An alternative therapeutic option is mandatory in a subset of patients regarded as being at high risk for stroke because anticoagulant therapy was either contraindicated or failed clinically with recurrent transient ischemic attacks/transient symptoms associated with brain infarction. In these selected cases, endovascular stent placement seems to be a safe and effective option to restore vessel lumen integrity and prevent stroke.

Juxtarenal Inflammatory Aneurysm Treated with Bilateral Iliac-Renal Bypass Using the Gore Hybrid Device and Total Sealing of the Aneurysmal Sac with a Nellix Device.

The aim of this study is to present the treatment of a juxtarenal inflammatory aneurysm using a Nellix device (Endologix, Inc., Irvine, CA) to seal the entire aneurysmatic aorta combined with bilateral iliac-renal bypass using the Gore hybrid vascular graft (W. L. Gore & Associates, Inc., Flagstaff, AZ). A 63-year-old man was diagnosed with a 6-cm juxtarenal inflammatory aneurysm. It was initially decided to treat him with an aorto-aortic bypass and to revascularize the 2 renal arteries with "graft to renal artery bypass" using Gore hybrid vascular grafts. Due to the high intraoperative bleeding preparing the proximal neck and the tight adhesion of the aorta to the adjacent structures, we decided to change our plans and to treat the patient using the Nellix system combined with bilateral iliac-renal bypass using the Gore hybrid vascular grafts. Contrast computed tomography control at 1 month showed complete sealing of the aneurysm sac and patent iliac renal bypasses. The reported case demonstrated that the Nellix Endovascular Aneurysm Sealing system combined with Gore hybrid vascular grafts for bilateral iliac-renal bypass showed that it can be an effective modality for the treatment of juxtarenal, inflammatory aortic aneurysm and revascularization of the renal arteries from the distal iliac arteries.

Treatment of a Juxtarenal Aneurysm with a Parallel Graft in the Left Renal Artery and Polymer-Based Technology to Seal the Entire Aneurysmal Sac.

BACKGROUND: Presenting the treatment of a juxtarenal aneurysm using a Nellix device combined with a chimney stent in a renal artery. CASE REPORT: A 72-year-old woman was diagnosed with a 5.5-cm bilobed juxtarenal aneurysm. She underwent successful aneurysm repair with the Nellix system combined with a chimney stent in the left renal artery. Angio computed tomography control showed complete sealing of the aneurysm sac and patent chimney stent. CONCLUSIONS: Endovascular aneurysm sealing combined with chimney may be a valid way to treat juxtarenal aneurysms, and the conformable polymer-filled endobags may provide a durable seal around the chimney-graft preventing gutter formation.

Extra-anatomical bypass: a surgical option for recurrent aortic coarctation.

Background. Balloon aortoplasty with or without stenting is a less invasive alternative to open surgery for the management of recurrent isthmic coarctation. However, in patients with previous small size tube graft, an open surgical correction is mandatory and, in most cases, an anatomical aortic reconstruction is carried out. Methods. We present the case of a 48-year-old woman with recurrent aortic coarctation and systemic hypertension with systolic value around 190-200 mmHg and preoperative systolic pressure gradient 70 mmHg, submitted to an extra-anatomical bypass. Through a median sternotomy, an extra-anatomical bypass from ascending to descending aorta was performed. Results. No intra- or postoperative complications were observed. The postoperative pressure gradient was 10 mmHg and the systolic pressure ranged from 130 to 140 mmHg. Conclusion. The extra-anatomical bypass can be considered an effective and safe alternative to the anatomical aortic reconstruction in the cases with recurrent aortic coarctation unfit for endovascular treatment.

Outcomes in the emergency endovascular repair of blunt thoracic aortic injuries.

Thoracic aorta blunt injury (BAI) is a highly lethal lesion. A large number of victims die before obtaining emergency care. Thoracic endovascular aneurysm repair (TEVAR) is a less invasive method compared with open surgery and may change protocols for BAI treatment. This retrospective study was developed to evaluate the potential issues about thoracic endografting in the management of these patients. Twenty-seven patients with a BAI underwent aortic stent grafting. Intervention was preceded by the treatment of more urgent associated lesions in nine cases. In-hospital mortality was 7.4%. No paraplegia or ischemic complications developed because of the coverage of the left subclavian artery. In one case (3.2%), a type I endoleak was detected, proximal endograft infolding in two cases (7.4%) and endograft distal migration in further two cases were detected during follow-up (6-110 months). Thoracic endovascular aneurysm repair of BAI showed encouraging results in terms of perioperative mortality and morbidity. Concerns still remain about the potential mid- and long-term complications in younger patients.