Femoral tripod arteries: Surgical anatomic variants.

AIM: To describe the surgical anatomy of the femoral tripod arteries and their anatomical variants. MATERIALS AND METHODS: Patients who underwent vascular surgery by external arciform approach of the Scarpa between May 2022 and July 2022 were selected. The surgical anatomy was assessed by direct observation. The origin and the course of major branches of the femoral artery (FA) were studied. Diameters and the distance of the origin of the femoral profunda artery (FPA) from the midpoint of the inguinal ligament was measured in millimeters and recorded. The observed anatomical variations were photographed and compared to those in the literature. RESULTS: A total of 40 patients (34 men, 85%) were included. The median diameter of the common femoral artery (CFA) was 9mm (IQR: 7-12mm). The Modal bifurcation was noted in 95% of cases. The collateral branches of the CFA were found to be distributed as follows: the superficial circumflex iliac artery (SCIA) in 34 cases (85%), the superficial epigastric artery (SEA) in 22 cases (55%), the deep external pudic artery in 16 cases (40%), and the superficial external pudic artery in 18 cases (45%). The median diameter of the FPA was 5mm (IQR: 4-6mm). The FPA originated from the posterolateral side of the CFA in 90% of cases, from the posterior side in 5% of cases and from the medial side in 5% of cases. The median diameter of the SFA was 6mm (IQR: 4-9mm). CONCLUSION: The anatomic variants of the femoral tripod arteries are extremely frequent. Therefore, it is important to recognize the anatomy in order to avoid possible diagnostic errors and to minimize the risk of per and post procedural complications.

The challenge of gate cannulation during endovascular aortic repair: A hypothesis of simplification.

AIM: One of the technical problems which can be encountered during the endovascular repair (EVAR) of abdominal aortic aneurysms, is represented by the challenge of cannulation of the contralateral gate after the opening of the main body of the endograft, especially in case of tortuous aorta-iliac anatomy. Aim of this work is to propose a hypothesis of simplification, verifying the possibility to maximize the area available for the cannulation of the contralateral gate by simulating an oblique distal end of the leg of the most used devices, without affecting the correct sealing between the main body and the iliac extension. METHODS: Data about the contralateral gate of the main body of endografts most used for EVAR were analyzed. The elliptical sectional area resulting from the simulation of the oblique cut was calculating with some geometric formulas. Then the gain of "disposable area" for the cannulation of the contralateral gate was calculated as a percentage of the elliptical area resulting in maximum distal oblique cut, with respect to the nominal circular area of the base. RESULTS: The only endografts which could undergo an oblique cut without losing the sealing between the main body and the contralateral limb were the Incraft, the Treovance and the Ovation, for which it would be possible to obtain a surface gain up to 84%, 22.8% and 14.4% respectively (being 9.8% in case of Ovation with the main body 29 and 34). A simulation of oblique cut was also performed on the endografts which currently do not allow to do so without a loss of sealing, assuming to lengthen the contralateral gate of an arbitrary measure of 10mm. In these cases, the percentage of surface gain was greater for endoprostheses which had a smaller diameter of the contralateral leg. CONCLUSIONS: The oblique cut of the contralateral gate allowed a gain of the surface available for the cannulation, however it was not applicable to all models of currently available endoprostheses, unless of a loss of sealing between the main body and the contralateral iliac limb.

Initial experience with the inspire MD C-Guard stent in the treatment of carotid artery disease.

OBJECTIVE: One of the main issue concerning the treatment of carotid artery stenosis is about the use of stents which could offer the best navigability through the lesion and the smallest "maximum unprotected circular area", ensuring the lower risk of neurological complication both intraprocedurally and in the long term. Recently, the Inspire MD technology (Tel Aviv, Israel) presented the new stent Inspire MD C-Guard, a bare-metal stent covered by a micron level mesh (MicroNet).We report our experience about the use of this novel stent in the endovascular treatment of carotid artery stenosis, with some technical considerations. METHODS: Data about patients in whom the Inspire MD C-Guard was used for the treatment of carotid artery diseases were retrospectively collected and analyzed. RESULTS: The procedure was completed in all patients without any intraoperative complications. Postoperative course was uneventful in all cases and no complications have been recorded till now. CONCLUSIONS: In our limited experience, the Inspire MD C-Guard has proven to be a safe stent for the treatment of carotid artery diseases. However large studies are needed to better explain strengths and weaknesses of this device.

Variability of Origin of Splanchnic and Renal Vessels From the Thoracoabdominal Aorta.

OBJECTIVE: To analyze the variability of origin of the celiac trunk (CT), the superior mesenteric artery (SMA), the right renal artery (RRA), and the left renal artery (LRA) in terms of mutual distances, angle from the sagittal aortic axis (clock position), and ostial diameters on computed tomography angiographies (CTAs) in three groups of patients. METHODS: One hundred and fifty CTAs of 50 patients with a non-dilated thoracoabdominal aorta (group A), 50 with thoracoabdominal aneurysm (B), and 50 with infrarenal aneurysm (C) were reviewed. The measurements performed on CTAs, as well as the patients' age, sex, and body surface area, were analyzed. p values <.05 were considered statistically significant. RESULTS: The clock position of the CT and the SMA, the diameters of all vessels, and the distance of the CTeSMA followed a Gaussian distribution. In contrast, the clock position of the renal vessels did not follow a normal distribution, and nor did the distances of the SMA-RRA, SMA-LRA, RRA-LRA or the distances between the renal arteries and the aortic bifurcation. The same values did not differ significantly among the three groups, with the exception of the distances between the renal arteries and the aortic bifurcation, significantly greater in group C. The clock position of the LRA and the distances of the SMA-LRA, SMA-RRA, RRA-LRA and between both renal arteries and the aortic bifurcation showed a significant correlation with the increase of aortic diameter. CONCLUSION: The anatomic variability of the origin of both the CT and the SMA in terms of clock position and mutual distances followed a Gaussian distribution, regardless of group. The same applies to the ostial diameters of renal and visceral vessels. In contrast, the origin of the renal vessels had a statistically significant heterogeneity that seemed to be correlated with the increase of aortic diameter in the mesenteric and renal aortic region.

Treatment options for visceral artery aneurysms: ten year experience.

AIM: Open surgical repair (OSR) and endovascular techniques (ET) are both described in the literature for treating visceral artery aneurysms (VAAs). Aim of this study is to report a two-center experience of patients treated for a VAA using either OSR or ET, analyzing perioperative outcomes. METHODS: Clinical data of 32 VAAs in 32 patients treated between January 2001 and May 2011 were retrospectively reviewed and outcomes analyzed. RESULTS: Eighteen patients were men (56.3%). Median age was 64 years (range 26-79). Sixteen aneurysms were symptomatic: half of them were ruptured causing hemoperitoneum or gastrointestinal bleeding. ET were employed in 19 cases (59%) using covered stents (7 patients), coil embolization (5), plug placement (1), thrombin injection (2) and multiple associated techniques (4). OSR consisted in aneurysmectomy with end to end anastomoses (5 patients) or interposition graft (1), aneurysm ligation (4), splenectomy (2). One patient died during open surgery for hemoperitoneum due to VAA rupture (3%). OSR and ET had similar perioperative complication rates (5.2% vs. 15.3%, P=0.76). OSR had a longer in-hospital stay than ET (8 vs. 4 days, P=0.04). The presence of pancreatitis and alcohol abuse were more frequent in patients who presented with VAAs rupture. Clinical presentation with hemoperitoneum or aneurysm rupture were associated with higher mortality, regardless of the type of treatment. CONCLUSION: Both OSR and ET offered a safe way to treat VAAs in our experience.

Treatment of significant carotid artery stenosis in 1824 patients.

AIM: We report our experience of thirteen years of treatment of significant carotid artery stenosis. METHODS: Data of all consecutive patients who came to our Division for a significant carotid artery stenosis from January 1999 to January 2012 were collected about patients' demographic, cardiovascular risk factors, neurological symptoms and treatment (carotid endarterectomy, carotid artery stenting or best medical therapy). Retrospective review was performed and the occurrence of death, major cerebrovascular events (major stroke, minor stroke) and myocardial infarction (MI) were recorded both at 30-day and at long-term. Analysis was performed among groups by means of JMP 5.1(®). RESULTS: Of 1824 patients who were admitted to our Department for a significant carotid stenosis, 582 were unsuitable for surgery and underwent carotid artery stenting (CAS, Group A). Three hundred and seventy-three of them were symptomatic (64.1%). Carotid endarterectomy (CEA) was performed in 1030 patients (Group B), 741 (71.9%) of them were symptomatic. The remaining patients (Group C) were treated using best medical therapy (BMT). At 30-day CEA compared to CAS and BMT was associated with higher risk of MI (2.1% vs. 0.2%, and 0.4% respectively, P<0.05), most of all in asymptomatic patients. CEA had a higher risk of cranial nerve injuries than CAS (3.3% vs. 0%, P<0.001). Both risk of death and major neurological complications were similar among the three groups in both symptomatic and asymptomatic patients. At long-term, risk of stroke after CEA was similar to that after CAS, both for symptomatic and asymptomatic patients, while risk of 1-year stroke in Group C was higher than in Group A (P<0.001) and in Group B (P<0.001), for both symptomatic and asymptomatic patients. Risk of long-term MI was similar among the three groups. Mortality at long term in symptomatic patients was higher after CAS than after CEA (P=0.001). Also long-term mortality in Group C was higher than in Group A and B (both P<0.001) but only for asymptomatic patients. A procedure that lasted for more than 60 minutes, patients who had no prior Magnetic Resonance Angiography (MRA) or Computed Tomographic Angiography (CTA) study of the aortic arch were independent risk factors for major neurological complications after CAS. Symptomatic patients were likely to have more major neurological complications in the long term if they were treated with BMT only. CONCLUSION: In our experience, CAS offered a valid alternative for both symptomatic and asymptomatic patients who were poor candidates for CEA, with results that compared favourably to those of CEA both at 30-day and at long-term. Patients who couldn't be operated on neither with CAS nor with CEA had a lower risk of MI at 30-day but a higher risk of stroke during the first year, especially if they had previously experienced neurological symptoms.

Long-term results of PTFE trilaminate graft versus venous graft and composite graft for below-the-knee revascularization.

AIM: We report our experience with the use of PTFE trilaminate graft Advanta SST (Atrium Maquet™) versus autologous great saphenous vein (AGSV) and composite PTFE trilaminate-vein graft for below-the-knee (BTK) revascularization. METHODS: Data of all consecutive patients who underwent either a BTK or a distal femoro-popliteal bypass from January 2004 to March 2013 using Advanta SST, AGSV or composite Advanta SST-vein graft were retrospectively reviewed and outcomes were analyzed. Kaplan-Meier method with Log-rank test was used to estimate survival, limb salvage and patency rates. Chi-square test was used to evaluate risk factors affecting outcomes. P value <0.05 was considered significant. RESULTS: Sixty-one patients (48 males, 78.7%; median age 73 years, IQR 66-80) underwent a BTK/distal revascularization for peripheral artery disease causing critical limb ischemia (52 patients, 85.2%) or disabling claudication (9 patients). Advanta SST graft was used in 17 patients (group A), AGSV in 30 (Group B) and composite Advanta-AGSV graft in the remaining 14 (group C). Patients' demographics and risk factors were similar among the three groups, being hypertension and smoke the most frequent comorbidities. When Advanta SST was employed, the median duration of intervention was significantly lower than using vein or composite grafts (212 minutes, IQR 177-257; 270 minutes, IQR 220-375, P=.02; 327.5 minutes, IQR 252.5-405, P=0.003 respectively). At 30-days, wound complications tended to be significantly higher in Group B (13.3%) and C (11.7%) than in group A (0%), P=0.02. At long term, survival, primary assisted and secondary patency rates did not differ significantly among the three groups. Limb salvage was similar as well among group A, B and C (P=0.29), being 81.2+9.7%, 89.4+5.8% and 67.7+13.5% respectively at 1 year and 81.2+9.7%, 83.4%+7.9% and 54.2%+16.2% respectively at 3 years. Primary patency rate at 1 year was significantly better for group B than for group A and C (71.2+8.6%, 49.6+12.7% and 47.6+14.1% respectively, P=0.02), but after 1 year the patency rate for group B and A was similar (55.5+10.6% and 49.6+12.7% respectively), being for group C significantly worse (19+11.8%). A history of previous or current smoke affected significantly primary patency rate in group A (RR 0.39, 95%CI 0.08-0.95, P=0.03). CONCLUSION: Long-term results of the use of Advanta SST graft for BTK/distal revascularization seems to be promising, with significant lower duration of the operation and wound complications. At long term, survival, limb salvage, primary assisted and secondary patency rates did not differ significantly among the three groups. The AGSV still remains the best graft in terms of primary patency at 1 year, but after one year primary patency rates using the Advanta SST compare favorably to those of AGSV, while composite bypass grafts have the worst performance. These results need to be increased further.

Recurrent pulmonary embolism secondary to popliteal vein aneurysm with intraluminal wall ulcer.

The popliteal vein is the most frequent site of venous aneurysm. Surgical treatment is indicated above a 2.5 cm diameter to prevent complications, notably deep venous thrombosis and pulmonary embolism (PE). Here we report a case of recurrent episodes of severe PE, leading to cardio-circulatory shock caused by a popliteal vein aneurysm (PVA) despite oral anticoagulant therapy. When surgical correction of the aneurysm was performed, we found an ulcerative lesion in the inner aspect of the vein that was acting as a 'thrombogenic focus' inside the aneurysm. An accurate inspection of the intimal wall is always important during surgery of PVA, particularly when tangential resection is performed.

Ulnar artery aneurysm: case report and review of the literature.

AIM: We report a case of ulnar and palmar arch artery aneurysm in a 77 years old man without history of any occupational or recreational trauma, vasculitis, infections or congenital anatomic abnormalities. We also performed a computed search of literature in PUBMED using the keywords "ulnar artery aneurysm" and "palmar arch aneurysm". CASE REPORT: A 77 years old male patient was admitted to hospital with a pulsing mass at distal right ulnar artery and deep palmar arch; at ultrasound and CT examination a saccular aneurysm of 35 millimeters at right ulnar artery and a 15 millimeters dilatation at deep palmar arch were detected. He was asymptomatic for distal embolization and pain. In local anesthesia ulnar artery and deep palmar arch dilatations were resected. Reconstruction of vessels was performed through an end-to-end microvascular repair. Histological examination confirmed the absence of vasculitis and collagenopaties. In postoperative period there were no clinical signs of peripheral ischemia, Allen's test and ultrasound examination were normal. At follow-up of six months, the patient was still asymptomatic with a normal Allen test, no signs of distal digital ischemia and patency of treated vessel with normal flow at duplex ultrasound. CONCLUSION: True spontaneous aneurysms of ulnar artery and palmar arch are rare and can be successfully treated with resection and microvascular reconstruction.