Redefining postoperative hypertension management in carotid surgery: a comprehensive analysis of blood pressure homeostasis and hyperperfusion syndrome in unilateral vs. bilateral carotid surgeries and implications for clinical practice.

Background: This study evaluates the implications of blood pressure homeostasis in bilateral vs. unilateral carotid surgeries, focusing on the incidence of postoperative hypertension, hyperperfusion syndrome, and stroke as primary outcomes. It further delves into the secondary outcomes encompassing major adverse cardiovascular events and all-cause mortality. Methods: Spanning two decades (2002-2023), this comprehensive retrospective research encompasses 15,369 carotid referrals, out of which 1,230 underwent carotid interventions. A subset of 690 patients received open carotid procedures, with a 10-year follow-up, comprising 599 unilateral and 91 bilateral surgeries. The Society for Vascular Surgery Carotid Reporting Standards underpin our methodological approach for data collection. Both univariate and multivariate analyses were utilized to identify factors associated with postoperative hypertension using the Statistical Package for the Social Sciences (SPSS) Version 22 (SPSS®, IBM® Corp., Armonk, N.Y., USA). Results: A marked acute elevation in blood pressure was observed in patients undergoing both unilateral and bilateral carotid surgeries (p < 0.001). Smoking (OR: 1.183, p = 0.007), hyperfibrinogenemia (OR: 0.834, p = 0.004), emergency admission (OR: 1.192, p = 0.005), severe ipsilateral carotid stenosis (OR: 1.501, p = 0.022), and prior ipsilateral interventions (OR: 1.722, p = 0.003) emerged as significant factors that correlates with postoperative hypertension in unilateral surgeries. Conversely, in bilateral procedures, gender, emergency admissions (p = 0.012), and plaque morphology (p = 0.035) significantly influenced postoperative hypertension. Notably, 2.2% of bilateral surgery patients developed hyperperfusion syndrome, culminating in hemorrhagic stroke within 30 days. Intriguingly, postoperative stage II hypertension was identified as an independent predictor of neurological deficits post-secondary procedure in bilateral CEA cases (p = 0.004), attributable to hyperperfusion syndrome. However, it did not independently predict myocardial infarction or mortality outcomes. The overall 30-day stroke rate stood at 0.90%. Lowest incidence of post operative hypertension or any complications were observed in eversion carotid endartrertomy. Conclusion: The study identifies postoperative hypertension as a crucial independent predictor of perioperative stroke following bilateral carotid surgery. Moreover, the study elucidates the significant impact of bilateral CEA on the development of post-operative hyperperfusion syndrome or stroke, as compared to unilateral CEA. Currently almost 90% of our carotid practice is eversion carotid endartrerectomy.

Systematic review of cardiovascular neurocristopathy-contemporary insights and future perspectives.

Introduction: Neural crest cells (NCCs) are multipotent and are attributed to the combination of complex multimodal gene regulatory mechanisms. Cardiac neural crest (CNC) cells, originating from the dorsal neural tube, are pivotal architects of the cardio-neuro-vascular domain, which orchestrates the embryogenesis of critical cardiac and vascular structures. Remarkably, while the scientific community compiled a comprehensive inventory of neural crest derivatives by the early 1980s, our understanding of the CNC's role in various cardiovascular disease processes still needs to be explored. This review delves into the differentiation of NCC, specifically the CNC cells, and explores the diverse facets of non-syndromic cardiovascular neurocristopathies. Methods: A systematic review was conducted as per the PRISMA Statement. Three prominent databases, PubMed, Scopus, and Embase, were searched, which yielded 1,840 studies. We excluded 1,796 studies, and the final selection of 44 studies formed the basis of this comprehensive review. Results: Neurocristopathies are a group of genetic disorders that affect the development of cells derived from the NC. Cardiovascular neurocristopathy, i.e., cardiopathy and vasculopathy, associated with the NCC could occur in the form of (1) cardiac septation disorders, mainly the aortico-pulmonary septum; (2) great vessels and vascular disorders; (3) myocardial dysfunction; and (4) a combination of all three phenotypes. This could result from abnormalities in NCC migration, differentiation, or proliferation leading to structural abnormalities and are attributed to genetic, familial, sporadic or acquired causes. Discussion: Phenotypic characteristics of cardiovascular neurocristopathies, such as bicuspid aortic valve and thoracic aortic aneurysm, share a common embryonic origin and are surprisingly prevalent in the general population, necessitating further research to identify the underlying pathogenic and genetic factors responsible for these cardiac anomalies. Such discoveries are essential for enhancing diagnostic screening and refining therapeutic interventions, ultimately improving the lives of individuals affected by these conditions.

Comparing the Efficacy of Different Maintenance Intervals on Preventing Disease Recurrence in Patients with A History of Periodontal Treatment.

Background: Scheduled maintenance appointments after periodontal treatment are very much critical for the success of the treatment. This is necessary for patients seeking to prevent disease recurrence and maintain oral health. Materials and Methods: In this study, we conducted a comprehensive analysis to assess the efficacy of various maintenance intervals in preventing disease recurrence among patients with a history of periodontal treatment. We gathered data from a diverse group of patients who had undergone periodontal treatment and tracked their oral health over an extended period. Results: Our findings reveal compelling insights into the optimal maintenance intervals. Patients who attended maintenance appointments at three-month intervals showed a significant reduction in disease recurrence by 40%, compared to those at six-month intervals. Moreover, those on annual intervals experienced a disease recurrence rate of 60. Conclusion: In conclusion, our study underscores the importance of regular maintenance appointments after periodontal treatment. Patients who attend appointments every three months have a significantly lower risk of disease recurrence. These findings emphasize the need for tailored maintenance schedules to ensure long-term oral health.

Mobile health technologies to improve walking distance in people with intermittent claudication.

BACKGROUND: Peripheral arterial disease (PAD) is the obstruction or narrowing of the large arteries of the lower limbs, which can result in impaired oxygen supply to the muscle and other tissues during exercise, or even at rest in more severe cases. PAD is classified into five categories (Fontaine classification). It may be asymptomatic or various levels of claudication pain may be present; at a later stage, there may be ulceration or gangrene of the limb, with amputation occasionally being required. About 20% of people with PAD suffer from intermittent claudication (IC), which is muscular discomfort in the lower extremities induced by exertion and relieved by rest within 10 minutes; IC causes restriction of movement in daily life. Treatment for people with IC involves addressing lifestyle risk factors. Exercise is an important part of treatment, but supervised exercise programmes for individuals with IC have low engagement levels and high attrition rates. The use of mobile technologies has been suggested as a new way to engage people with IC in walking exercise interventions. The novelty of the intervention, low cost for the user, automation, and ease of access are some of the advantages mobile health (mhealth) technologies provide that give them the potential to be effective in boosting physical activity in adults. OBJECTIVES: To assess the benefits and harms of mobile health (mhealth) technologies to improve walking distance in people with intermittent claudication. SEARCH METHODS: The Cochrane Vascular Information Specialist conducted systematic searches of the Cochrane Vascular Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, and CINAHL, and also searched the World Health Organization International Clinical Trials Registry Platform (WHO ICTRP) and ClinicalTrials.gov. The most recent searches were carried out on 19 December 2022. SELECTION CRITERIA: We included randomised controlled trials (RCTs) in people aged 18 years or over with symptomatic PAD and a clinical diagnosis of IC. We included RCTs comparing mhealth interventions to improve walking distance versus usual care (no intervention or non-exercise advice), exercise advice, or supervised exercise programmes. We excluded people with chronic limb-threatening ischaemia (Fontaine III and IV). DATA COLLECTION AND ANALYSIS: We used standard Cochrane methods. Our primary outcomes were change in absolute walking distance from baseline, change in claudication distance from baseline, amputation-free survival, revascularisation-free survival. Our secondary outcomes were major adverse cardiovascular events, major adverse limb events, above-ankle amputation, quality of life, and adverse events. We used GRADE to assess the certainty of the evidence. MAIN RESULTS: We included four RCTs involving a total of 614 participants with a clinical diagnosis of IC. The duration of intervention of the four included RCTs ranged from 3 to 12 months. Participants were randomised to either mhealth or control (usual care or supervised exercise programme). All four studies had an unclear or high risk of bias in one or several domains. The most prevalent risk of bias was in the area of performance bias, which was rated high risk as it is not possible to blind participants and personnel in this type of trial. Based on GRADE criteria, we downgraded the certainty of the evidence to low, due to concerns about risk of bias, imprecision, and clinical inconsistency. Comparing mhealth with usual care, there was no clear evidence of an effect on absolute walking distance (mean difference 9.99 metres, 95% confidence interval (CI) -27.96 to 47.93; 2 studies, 503 participants; low-certainty evidence). None of the included studies reported on change in claudication walking distance, amputation-free survival, or revascularisation-free survival. Only one study reported on major adverse cardiovascular events (MACE) and found no clear difference between groups (risk ratio 1.37, 95% CI 0.07 to 28.17; 1 study, 305 participants; low-certainty evidence). None of the included studies reported on major adverse limb events (MALE) or above-ankle amputations. AUTHORS' CONCLUSIONS: Mobile health technologies can be used to provide lifestyle interventions for people with chronic conditions, such as IC. We identified a limited number of studies that met our inclusion criteria. We found no clear difference between mhealth and usual care in improving absolute walking distance in people with IC; however, we judged the evidence to be low certainty. Larger, well-designed RCTs are needed to provide adequate statistical power to reliably evaluate the effects of mhealth technologies on walking distance in people with IC.

Caries risk assessment by Caries Management by Risk Assessment (CAMBRA) Protocol among the general population of Pakistan-a multicenter analytical study.

Background: Caries risk (CR) assessment tools are used to properly identify individuals with caries risk and to improve preventive procedures and programs. A tool such as CAMBRA determines the precise protective factors of caries and identifies an individual's specific therapeutic intervention. The purpose of this study was to assess the caries risk using the CAMBRA protocol among the general population of Pakistan. Methods: This multicentre analytical study was conducted in ten dental hospitals in different provinces of Pakistan and the caries risk assessment was carried out using a questionnaire that was designed using the Caries Management by Risk Assessment (CAMBRA) protocol. All 521 participants were intra-orally examined to assess oral hygiene status and the presence of disease. Multiple logistic regression test was performed for analysis. Results: A higher number of participants (61.2%) were found to be in the moderate risk category of caries risk assessment. The males are 51% less likely to have caries compared to the females (AOR = 0.49, P = 0.081). The majority of participants (71.3%) had one or more disease indicators, with white spots and visible cavities. Those with visible, heavy plaque were 13.9 times more likely to have caries compared to those without (AOR = 13.92, P < 0.001). Those using calcium and phosphate during the last 6 months were 90% less likely to have caries compared to those not using them (AOR = 0.10, P < 0.001). There was no significant interaction between all eight risk factors retained in the final model (P > 0.05), the Hosmer and Lemeshow Test P < 0.001, classification accuracy = 87.1%, and AUC = 91.2%. Conclusion: The caries risk among the general population of Pakistan is moderate, with significant variation among age groups, education levels, and socioeconomic status.

Effectiveness of Chitosan versus Natural Aloe Vera on Candida Adherence in Denture Soft Lining Material.

Background: Soft denture lining materials act as a cushion between the denture base and tissues. Alongside having many advantages, its main problem is candida growth due to its rubbery and porous texture. Many interventions have been performed to halt the growth of candida within soft lining materials such as the use of antifungal therapy and strict oral and denture hygiene but there are consequences such as recurrence, drug resistance, and toxicity related to these interventions. Since natural agents such as aloe vera and chitosan have been proven to have antibacterial and antifungal properties with minimum adverse effects, this study aimed to study the effectiveness of chitosan and aloe vera powders incorporated within denture soft lining materials against candida adherence. Methodology. A total of 60 soft-lining material samples were prepared that were equally divided into three groups, viz., group 1 (chitosan incorporation), group 2 (aloe vera incorporation), and group 3 (control). Candida was obtained from the microbiology lab to form a candidal suspension, diluted in 0.9% NaCl to match the McFarland standard bacteriologic solution. Samples were incubated at 37°C for 24 hours in test tubes containing 100 mL of the candidal suspension and 9.9 mL of the previously prepared Sabouraud dextrose agar. Crystal violet stain was used to stain the adhering cells by fixing them with methanol 80%. For each sample, the adhering candida cells were counted on three standard fields by using an inverted light microscope, and the mean of those fields was recorded. Results: The mean value for samples containing aloe vera was 41.15, while the mean values for samples containing chitosan and the control group were 16.05 and 79.1, respectively. Of all the three groups, aloe vera powder had a significant efficacy against candida growth as compared to the chitosan and control groups (P value = 0.001). Conclusion: Both herbal agents were effective against candida growth. In comparison, aloe vera was more effective against candida growth compared to chitosan.

An international, multispecialty, expert-based Delphi Consensus document on controversial issues in the management of patients with asymptomatic and symptomatic carotid stenosis.

OBJECTIVE: Despite the publication of various national/international guidelines, several questions concerning the management of patients with asymptomatic (AsxCS) and symptomatic (SxCS) carotid stenosis remain unanswered. The aim of this international, multi-specialty, expert-based Delphi Consensus document was to address these issues to help clinicians make decisions when guidelines are unclear. METHODS: Fourteen controversial topics were identified. A three-round Delphi Consensus process was performed including 61 experts. The aim of Round 1 was to investigate the differing views and opinions regarding these unresolved topics. In Round 2, clarifications were asked from each participant. In Round 3, the questionnaire was resent to all participants for their final vote. Consensus was reached when ≥75% of experts agreed on a specific response. RESULTS: Most experts agreed that: (1) the current periprocedural/in-hospital stroke/death thresholds for performing a carotid intervention should be lowered from 6% to 4% in patients with SxCS and from 3% to 2% in patients with AsxCS; (2) the time threshold for a patient being considered "recently symptomatic" should be reduced from the current definition of "6 months" to 3 months or less; (3) 80% to 99% AsxCS carries a higher risk of stroke compared with 60% to 79% AsxCS; (4) factors beyond the grade of stenosis and symptoms should be added to the indications for revascularization in AsxCS patients (eg, plaque features of vulnerability and silent infarctions on brain computed tomography scans); and (5) shunting should be used selectively, rather than always or never. Consensus could not be reached on the remaining topics due to conflicting, inadequate, or controversial evidence. CONCLUSIONS: The present international, multi-specialty expert-based Delphi Consensus document attempted to provide responses to several unanswered/unresolved issues. However, consensus could not be achieved on some topics, highlighting areas requiring future research.

Barriers and challenges faced by orthodontists in providing orthodontic care and implementing new innovative technologies in the field of orthodontics among children and adults: a qualitative study.

Orthodontic treatment requires the cooperation of patients as well as orthodontists. Therefore, the aim of the study was to investigate and address the challenges and barriers orthodontists have in achieving the desired orthodontic results, as well as make recommendations for ways to address the stated problems and introduce new innovative technologies to the area of orthodontics. This qualitative study wasbased on the grounded theory. Twelve orthodontists participated in face-to-face interviews, which were primarily comprised of open-ended questions. Data analysis was carried out manually using the "by hand" method. Orthodontists between the age group of 29-42 were interviewed. The answers varied depending on the years of experience of the interviewees. Teenagers and boys were found to be most non-compliant with the treatment. The average treatment span ranged between 6 months for mild cases up to 3 years for severe orthodontic cases occurring most commonly in government hospitals. Patient compliance plays a major role in orthodontics. Poor oral hygiene maintenance, brackets breakage by patients, and missed appointments were the major concerns mentioned by participants and hindered getting the desired results. Patients' main worries were related to the cost of therapy, premolar extractions, the length of treatment, and the possibility of relapse. Patient counseling and reinforcement at the start of the treatment can help to overcome the challenges and barriers in orthodontics since patient motivation is a very important factor in obtaining the desired results. It is recommended to conduct more training sessions for the orthodontists in order to introduce them to new technological paradigms.

Comparison of the elastic recovery and strain-in-compression of commercial and novel vinyl polysiloxane impression materials incorporating a novel crosslinking agent and a surfactant.

This study aims to formulate experimental vinylpolysiloxane (VPS) impression materials and compare their elastic recovery and strain-in-compressions with three commercial VPS materials (Aquasil, Elite, and Extrude). Five experimental materials (Exp), two hydrophobic (Exp-I and II) and three hydrophilic (Exp-III, IV and V) were developed. Exp 1 contained vinyl-terminated poly-dimethyl siloxane and a conventional cross-linking agent (poly methylhydrosiloxane), while Exp- II contained a novel cross-linking agent that is tetra-functional dimethyl-silyl-ortho-silicate (TFDMSOS). Exp III-V (hydrophilic materials) were formulated by incorporating different concentrations of non-ionic surfactant (Rhodasurf CET-2) into Exp II formulation. Measurement of elastic recovery and strain-in-compression for commercial and experimental materials were performed according to ISO4823 standard using the calibrated mechanical testing machine (Tinius Olsen). One-way analysis of variance (one-way ANOVA) and Tukey's post-hoc (HSD) test were used for statistical analysis and a p-value of ≤ 0.05 was considered significant. Exp-I has statistically similar values to commercial VPS. The Exp-II showed the highest elastic recovery, while % elastic recovery was reduced with the addition of the non-ionic surfactant (Rhodasurf CET-2). The % reduction was directly related to the concentration of Rhodasurf CET-2. In addition, Exp II had significantly higher strain-in-compression values compared to Exp-I and commercial materials. These values were further increased with the addition of a non-ionic surfactant (Rhodasurf CET-2) was added (Exp-III, IV and V).

International Union of Angiology consensus document on vascular compression syndromes.

Vascular compression syndromes (VCS) are rare diseases, but they may cause significant symptoms interfering with the quality of life (QoL) of patients who are often in their younger age. Given their infrequent occurrence, multiform clinical and anatomical presentation, and absence of dedicated guidelines from scientific societies, further knowledge of these conditions is required to investigate and treat them using modern imaging and surgical (open or endovascular) techniques. This consensus document will focus on known VCS, affecting the arterial and venous system. The position paper, written by members of International Union of Angiology (IUA) Youth Committee and senior experts, will show an overview of pathophysiology, diagnostic, and therapeutical approaches for patients with VCS. Furthermore, this document will provide also unresolved issues that require more research that need to be addressed in the future.

Management of acute aortic syndrome with evolving individualized precision medicine solutions: Lessons learned over two decades and literature review.

Background: Thoracoabdominal acute aortic syndrome is associated with high morbidity and mortality. We aim to scrutinize our evolving strategies for acute aortic syndrome (AAS) management using minimally invasive and adaptive surgical techniques over two decades. Methods: This is a longitudinal observational study at our tertiary vascular centre from 2002 to 2021. Out of 22,349 aortic referrals, we performed 1,555 aortic interventions over twenty years. Amongst 96 presented with symptomatic aortic thoracic pathology, 71 patients had AAS. Our primary endpoint is combined aneurysm-related and cardiovascular-related mortality. Results: There were 43 males and 28 females (5 Traumatic Aortic Transection (TAT), 8 Acute Aortic Intramural Hematoma (IMH), 27 Symptomatic Aortic Dissection (SAD) and 31 Thoracic Aortic Aneurysm (TAA) post-SAD) with a mean age of 69. All the patients with AAS received optimal medical therapy (OMT), but TAT patients underwent emergency thoracic endovascular aortic repair (TEVAR). Fifty-eight patients had an aortic dissection, of which 31 developed TAA. These 31 patients with SAD and TAA received OMT initially and interval surgical intervention with TEVAR or sTaged hybrId sinGle lumEn Reconstruction (TIGER). To increase our landing area, we performed a left subclavian chimney graft with TEVAR in twelve patients. The average follow-up duration was 78.2 months, and eleven patients (15.5%) had combined aneurysm and cardiovascular-related mortality. Twenty-six percentage of the patients developed endoleaks (EL), of which 15% required re-intervention for type II and III. Four patients who had paraplegia (5.7%) and developed renal failure died. None of our patients had a stroke or bowel ischaemia. Twenty patients had OMT, eight of these were patients with acute aortic hematoma, and all eight died within 30 days of presentation. Conclusion: Acute aortic hematoma is a sinister finding, which must be closely monitored, and consideration is given to early intervention. Paraplegia and renal failure result in an increased mortality rate. TIGER technique with interval TEVAR has salvaged complex situations in young patients. Left subclavian chimney increases our landing area and abolishes SINE. Our experience shows that minimally invasive techniques could be a viable option for AAS.

Why do guidelines recommend screening for abdominal aortic aneurysms, but not for asymptomatic carotid stenosis? A plea for a randomized controlled trial.

BACKGROUND: Current guidelines do not recommend screening for asymptomatic carotid artery stenosis (AsxCS). The rationale behind this recommendation is that detection of AsxCS may lead to an unnecessary carotid intervention. In contrast, screening for abdominal aortic aneurysms is strongly recommended. METHODS: A critical analysis of the literature was performed to evaluate the implications of detecting AsxCS. RESULTS: Patients with AsxCS are at high risk for future stroke, myocardial infarction and vascular death. Population-wide screening for AsxCS should not be recommended. Additionally, screening of high-risk individuals for AsxCS with the purpose of identifying candidates for a carotid intervention is inappropriate. Instead, selective screening for AsxCS should be considered and should be viewed as an opportunity to identify individuals at high risk for atherosclerotic cardiovascular disease and future cardiovascular events for the timely initiation of intensive medical therapy and risk factor modification. CONCLUSIONS: Although mass screening should not be recommended, there are several arguments suggesting that selective screening for AsxCS should be considered. The rationale supporting such selective screening is to optimize risk factor control and to initiate intensive medical therapy for prevention of future cardiovascular events, rather than to identify candidates for an intervention.

Impact of preoperative oral domperidone on gastric residual volume after clear fluid ingestion in patients scheduled for elective surgery: a randomized controlled trial.

INTRODUCTION: Oral domperidone is a prokinetic drug that enhances gastric emptying, which has a positive effect in decreasing gastric residual volume (GRV), subsequently decreasing the risk of pulmonary aspiration. This study aimed to assess the effect of preoperative oral domperidone on gastric residual volume, detected by ultrasound for patients undergoing elective surgery under general anesthesia. MATERIAL AND METHODS: This randomized double-blinded controlled placebo trial was conducted in 40 patients who were randomly assigned to two equal groups: the domperidone group (D) ( n = 20): patients received 400 mL of apple juice as a clear fluid, two hours preoperatively, and an oral domperidone 10 mg tablet; and the placebo group (P) ( n = 20): patients received 400 mL of apple juice as a clear fluid two hours preoperatively with a placebo tablet. Gastric residual volume detected by ultrasound was the primary outcome and postoperative nausea and vomiting (PONV) was the secondary outcome. RESULTS: There was no statistically significant difference in the mean gastric residual volume detected by ultrasound between groups after 1 hour ( P > 0.05). However, the mean gastric residual volume detected by ultrasound after 2 hours was statistically significantly lower with domperidone (55.95 ± 6.72 mL) than with the placebo group (70.22 ± 13.00 mL) ( P < 0.05). There was no statistically significant difference between groups regarding PONV, with a P -value > 0.05. CONCLUSIONS: Preoperative oral domperidone intake was effective in decreasing the GRV measured by ultrasound.

Two decades of experience in explantation and graft preserving strategies following primary endovascular aneurysm repair and lessons learned.

Objectives: We aim to scrutinize our evolving re-intervention strategies following primary endovascular aortic aneurysm repair (EVAR) - EVAR GORE SalvAge Fabric Technique (ARAFAT), aortic sac double breasting with endograft preservation, and stent-graft explantation. Methods: We performed 1,555 aortic interventions over the study period, including 910 EVARs. Factors associated with the need for reintervention and the likelihood of chronic fabric fatigue failure (CFFF) were investigated. Using conventional and innovative diagnostic modalities with Prone contrASt enHanced computed tomography Angiography (PASHA), 136 endoleaks (ELs) were identified (15 type I, 98 type II; 18 type III; 5 type IV). Results: Forty-four (4.84%) patients underwent re-intervention post-primary EVAR; 18 ARAFATs, 12 double breastings, and 14 explantations. Choice of re-intervention was based on patient fitness and mode of failure. Mean EL detection duration following primary EVAR was 53.3 ± 6.82 months, while mean time to re-intervention was 70.20 ± 6.98 months. The mean sac size before the primary EVAR and re-intervention was 6.00 ± 1.75 cm and 7.51 ± 1.94 cm, respectively. Polyester (61.40%) was the most commonly employed stent-graft material. Use of more than three modular stent-graft components (3.42 ± 1.31, p = 0.846); with the proximal stent-graft diameter of 31.6 ± 3.80 cm (p = 0.651) and the use of iliac limbs more than 17 mm (p = 0.364), all added together are contributing factors. We had one peri-operative mortality following explantation due to sepsis-induced multiorgan failure. Conclusions: Our re-intervention strategies matured from stent graft explantation to graft preservation with endovascular relining of the stent-graft. Graft preservation with aortic sacotomy and double breasting were used to manage concealed ELs due to aortic hygroma.

The contemporary design of endovascular aneurysm stent-graft materials: PTFE versus polyester.

Endovascular aneurysm repair of the abdominal aorta (EVAR) and of the thoracic aorta (TEVAR) have revolutionised therapeutic strategies in the management of aortic pathology, and endovascular repair is now an established and attractive alternative to open surgical repair (OSR) due to its superior short-term safety profile. However, opinions are divided regarding its long-term cost-effectiveness, which is reflected in the controversial NICE guidelines on abdominal aortic aneurysm (AAA) repair published in 2018, which advised against EVAR for elective aortic repair due to high secondary intervention rates and resultant associated costs. There is no doubt that OSR continues to have a valuable role to play in aortic repair, but it is not universally applicable, especially in older and sicker patients. Therefore, we should not dismiss EVAR and TEVAR without examining the reasons for long-term failure, and the most obvious starting point is stent graft material properties. Polytetrafluoroethylene (PTFE) and polyester are the two most common stent-graft materials; however, there has been no objective comparison of PTFE and polyester stent-graft post-procedural outcomes in EVAR and TEVAR, or even OSR. This lack of definitive data on different stent-graft materials and their configuration necessitates a comprehensive review to elucidate the post-procedural outcome in terms of endograft failure, cardiovascular events, and aortic-related mortality and morbidity.

TEVAR and EVAR, the unknown knowns of the cardiovascular hemodynamics; and the immediate and long-term consequences of fabric material on major adverse clinical outcome.

This review discusses the impact of endovascular aneurysm repair on cardiovascular (CV) hemodynamics and the role of stent-graft material, i.e., polytetrafluoroethylene (PTFE) vs. polyester in post-procedural outcomes. Endovascular aneurysm repair has been widely employed in the last decades for thoracic and abdominal aneurysm repair. However, aortic endografts are stiff and alter the native flow hemodynamics. This failure to simulate the native aorta could lead to added strain on the heart, manifesting as increased left ventricular strain, higher pulse pressure, and congestive heart failure later. This could result in adverse CV outcomes. Also, evidence is mounting to support the implication of stent-graft materials, i.e., PTFE vs. polyester, in adverse post-procedural outcomes. However, there is an absence of level one evidence. Therefore, the only way forward is to plan and perform a randomised controlled trial to demonstrate the alterations in the CV hemodynamics in the short and long run and compare the available stent-graft materials regarding procedural and clinical outcomes. We believe the best solution, for now, would be to reduce the stented length of the aorta. At the same time, in the longer term, encourage continuous improvement in stent-graft materials and design.

Management of retroperitoneal fibrosis with endovascular aneurysm repair in patients refractory to medical management.

Background: Early diagnosis and treatment of under-recognized retroperitoneal fibrosis (RPF) are essential before reaching the poorly responsive fibrotic stage. Although most patients respond to medical therapy, relapses and unresponsiveness are common. However, open surgery in medically resistant patients is associated with major adverse clinical events. Methods: This is a single-centre longitudinal study of optimal medical therapy (OMT) vs. endovascular aneurysm repair (EVAR) in patients presenting with RPF to our tertiary referral vascular centre. Out of 22,349 aortic referrals, we performed 1,555 aortic interventions over twenty years. Amongst them, 1,006 were EVAR, TEVAR and BEVAR. Seventeen patients (1.09%) had documented peri-aortic RPF. Results: Out of the 17 RPF patients, 11 received OMT only, while 6 underwent EVAR after the failure of OMT. 82% (n = 14) were male, and the median follow-up was 62.7 months (IQR: 28.2-106). Nine (52%) had immunoglobulin G4-related disease (4 OMT vs. 5 EVAR). EVAR patients had 100% technical success without perioperative mortality. Furthermore, all the EVAR patients were symptom-free following the intervention. Pre-operative aortic RPF index (maximum peri-aortic soft tissue diameter/maximum aortic diameter) was higher in the EVAR than in OMT. However, there was a significant decrement in the aortic RPF index following EVAR (P = 0.04). Conclusion: We believe that when optimal medical therapy fails in RPF, EVAR provides a promising outcome. Further studies are recommended to establish the role of endovascular repair.