Treatment of Aortoiliac Occlusive Lesions by Aortic Robotic Surgery: Learning Curve and Midterm Outcome.

BACKGROUD: The learning curve and midterm results of aortoiliac occlusive disease (AIOD) revascularization by robot-assisted laparoscopic (RAL) surgery may be known. METHODS: A prospective single-center study was conducted in the vascular surgery department of Georges Pompidou European Hospital (Paris, France). Patients with AIOD treated by RAL from February 2014 to February 2019 were included. Demographic characteristics, past medical history, Trans-Atlantic Inter-Society Consensus (TASC) lesions classifications, mortality, primary and secondary patency, as well as complication rates were collected. Safety was analyzed by the cumulative sum control chart method with a conversion rate of 10%, operative time by cumulative average-time model, and primary and secondary patency by the Kaplan-Meier method. RESULTS: Seventy patients were included, 18 (25.7%) with TASC C lesions and 52 (74.3%) with TASC D lesions. Before discharge, 14 (24.3%) patients had surgical complications. Among them, 10 (14.3%) required at least one reintervention. One (1.4%) patient died during the hospitalization. The learning curve in terms of safety (conversion rate) was 13 cases with an operating time of 220 minutes after 35 patients. During follow-up (median 37 months [21; 49]), 63 patients (91.3%) improved their symptoms, 53 (76.8%) became asymptomatic, and 3 graft limb occlusions occurred. The primary patency at 12, 24, 36, and 48 months was 94%, 92%, 92%, and 92%, respectively, while the secondary patency for the same intervals was 100%, 98.1%, 98.1%, and 98.1%, respectively. CONCLUSIONS: Robotic surgery in AIOD revascularization seems safe and effective; allowing to treat patients with few comorbidities and severe lesions, in a dedicated center experienced in RAL, with excellent patency. Prospective clinical trials should be performed to confirm safety.

Endovascular Treatment as an Alternative to Bypass Surgery for Juxtarenal Aortic Occlusion: Results from the CHAOS (CHronic Abdominal Aortic Occlusion, ASian Multicenter) Registry.

BACKGROUND: Juxtarenal aortic occlusion (JRAO), in which the occlusion of the aorta extends to just below the renal artery, is often treated by bypass surgery because of concerns about the risk of procedural failure and fatal embolization to abdominal organs when treated with endovascular treatment (EVT). This study assessed the outcome of EVT for JRAO compared with aorto-biiliac /aorto-bifemoral (AOB) or axillo-bifemoral (AXB) bypass. METHODS: A retrospective review of an international database created by 30 centers in Asia (CHronic Abdominal Aortic Occlusion, ASian Multicenter registry) was performed for patients who underwent revascularization for chronic total occlusion of the infrarenal aorta from 2007 to 2017. Of the 436 patients, 130 with JRAO (Forty-seven AOBs, 32 AXBs, and 51 EVTs) from 25 institutions were included in this study. RESULTS: Patients were significantly older in the AXB and EVT groups and more malnourished in the EVT group than the AOB group. EVT was attempted but failed in 1 patient. Seven patients (1 [2.1%] in the AOB group, 1 [3.1%] in the AXB group, and 5 [9.8%] in the EVT group) died during hospitalization, but most of the causes in the EVT group were not related to the revascularization procedure. No visceral embolism was observed, which had been concerned, even though protection was performed only in 2 cases of the EVT group. At the latest follow-up (median duration 3.0 years), the ankle-brachial pressure index was significantly higher in the order of AOB, EVT, and AXB. At 4 years, the estimated primary and secondary patency rates of the AOB group (87.5% and 90.3%, respectively) were significantly higher than the AXB group (66.7% and 68.6%, respectively). CONCLUSIONS: AOB remains the gold standard and should be the first choice for acceptable risk patients. For frail patients, EVT is a good option and likely preferable as a first-line treatment compared to AXB.

Contemporary outcomes of surgical decompression for functional popliteal entrapment syndrome.

BACKGROUND: Functional popliteal entrapment syndrome (FPES) is an under-recognized source of leg pain caused by dynamic compression of the popliteal vessels by surrounding musculature in the absence of anatomic abnormality. Late recognition and difficulty capturing this entity across imaging modalities can lead to significant morbidity in an often young and active patient population. Surgical outcomes and optimal diagnostic strategies remain uncertain. METHODS: We performed a retrospective cohort study of all patients undergoing surgical decompression for FPES at an academic medical center between 2018 and 2022. Preoperative symptoms, patient characteristics, imaging, operative details, and follow-up were captured. The primary outcome was symptomatic improvement at last clinic visit. Secondary outcomes included symptomatic improvement at 6 months and postoperative complications. RESULTS: A total of 24 extremities (16 patients) were included. The mean ± standard deviation age was 23.3 ± 6.4 years and 75.0% of patients were female. The median symptom duration before decompression was 27 months (interquartile range, 10.7-74.6 months). Preoperative symptom severity in the affected extremity was as follows: 33.3% limited from peak exercise, 25% unable to exercise, and 41.7% with debilitating symptoms that affected activities of daily living. Preoperative imaging with provocative maneuvers included duplex ultrasound (87.5%), magnetic resonance angiography (100%), and digital subtraction angiography (100%). Using digital subtraction angiography as the gold standard, the sensitivity for detection of FPES was 85.7% for duplex examination and 58.3% for magnetic resonance angiography. The median follow-up was 451 days (interquartile range, 281-635 days). Most patients demonstrated durable improvement in the affected extremity, with 29.2% realizing complete resolution of symptoms and 37.5% reporting symptomatic improvement at last clinic visit for a total of 66.7%; 20.8% had initial improvement, but developed recurrent symptoms and were found to have elevated compartment pressures consistent with chronic exertional compartment syndrome and were treated with formal fasciotomy. Repeat decompression was required in one extremity (4.2%) owing to recurrent symptoms. Two patients (8.3%) had minimal or no improvement in their affected extremity and workup for the cause of continued discomfort was ongoing. CONCLUSIONS: Delays in diagnosis of FPES are common. Provocative maneuvers until replication of symptoms across multiple imaging modalities may be necessary to reliably identify the disease process. Surgical decompression improved or completely resolved symptoms in two-thirds of extremities. Treating physicians should maintain suspicion for comorbid chronic exertional compartment syndrome, especially if symptoms recur or persist after decompression.

Telephone Health Coaching and Remote Exercise Monitoring (TeGeCoach) in Peripheral Arterial Occlusive Disease.

BACKGROUND: Supervised exercise programs are used to treat intermittent claudication (IC). Home-based exercise programs have been developed to lower barriers to participation. We studied the effects of one such exercise program (TeGeCoach) on self-reported walking ability in patients with IC. METHODS: In a pragmatic multicenter randomized controlled trial (registration number NCT03496948), 1982 patients with symp - tomatic IC insured by one of three German statutory health insurance funds received either telephone health coaching with remote exercise monitoring (TeGeCoach; n = 994) or routine care (n = 988). The primary outcome was the change in Walking Impairment Questionnaire (WIQ) scores after 12 and 24 months in the intention-to-treat population. The secondary outcomes were healthrelated quality of life, symptoms of depression or anxiety, health competence, patient activation, alcohol use, and nicotine depen - dence. RESULTS: There was a significant group difference in WIQ score in favor of TeGeCoach (p < 0.0001), amounting to 6.30 points at 12 months (Bonferroni-corrected 95% CI [4.02; 8.59], Cohen's d = 0.26) and 4.55 points at 24 months ([2.20; 6.91], d = 0.19). Some of the secondary outcomes also showed positive results in favor of TeGeCoach at 12 months with small effect sizes (d ≥ 0.20), including physical health-related quality of life and patient activation. The average daily step count was not higher in the TeGeCoach group. CONCLUSION: Significant improvements regarding symptom burden demonstrate the benefit of a home-based exercise program and thus expand the opportunities for guideline-oriented treatment of IC. Future studies should additionally address the effect of home-based exercise programs on clinical variables by means of, for example, the 6-minute walk test.

Percutaneous Aortoiliac Thromboendarterectomy for Acute Limb Ischemia.

Aortoiliac occlusive disease (AIOD) can occur from either chronic, progressive atherosclerotic disease, acute on chronic thrombosis or acute arterial embolism, and can all result in limb ischemia. Bypass surgery had long been the gold standard for treatment for AIOD, however, with advances in endovascular techniques, minimally invasive treatment of aortoiliac lesions has become the first line choice of management in many cases. Herein, we describe a case of utilizing the Inari ClotTriever to perform aortoiliac mechanical thrombectomy and the ARTIX thrombectomy system to perform an embolectomy the superficial femoral artery, highlighting new therapies to treat AIOD.

Mechanical thrombectomy in patients with stroke due to large vessel occlusion in the anterior circulation and low baseline NIHSS score.

We sought to verify the benefit of mechanical thrombectomy in patients with acute ischemic stroke due to large vessel occlusion in the anterior circulation and low National Institute of Health stroke scale score at presentation. The prospective database of our stroke center was screened for patients with acute ischemic stroke due to large vessel occlusion and a baseline National Institute of Health stroke scale score ≤5 that had undergone mechanical thrombectomy. Outcome measures were the modified Rankin Scale (mRS) score at 90 days, brain bleeding events and death at 90 days. Out of 459 patients, 17 (12 females, mean age 70 ± 14 years) with occlusion of M1 or M2 segment of middle cerebral artery and baseline National Institute of Health stroke scale score ≤5 underwent mechanical thrombectomy. Eight patients (47%) were treated within 6 hours from the onset, 5 (29%) were treated beyond 6 hours, and 4 (24%) were wake-up strokes. Effective mechanical thrombectomy was achieved in 16 patients (94%) and associated with excellent functional outcomes at 3 months (mRS 0-1) in 13 (76%). The asymptomatic brain-bleeding event was observed in one patient 4 days after effective mechanical thrombectomy concerning safety issues. One patient died 1 month after mechanical thrombectomy of a cause unrelated to stroke. Our findings favor a potential benefit of mechanical thrombectomy in patients with stroke due to large vessel occlusion and low National Institute of Health stroke scale score at presentation. These patients may also benefit from a prolonged time window for treatment.

Role of Vascular Smooth Muscle Cell Phenotype Switching in Arteriogenesis.

Arteriogenesis is one of the primary physiological means by which the circulatory collateral system restores blood flow after significant arterial occlusion in peripheral arterial disease patients. Vascular smooth muscle cells (VSMCs) are the predominant cell type in collateral arteries and respond to altered blood flow and inflammatory conditions after an arterial occlusion by switching their phenotype between quiescent contractile and proliferative synthetic states. Maintaining the contractile state of VSMC is required for collateral vascular function to regulate blood vessel tone and blood flow during arteriogenesis, whereas synthetic SMCs are crucial in the growth and remodeling of the collateral media layer to establish more stable conduit arteries. Timely VSMC phenotype switching requires a set of coordinated actions of molecular and cellular mediators to result in an expansive remodeling of collaterals that restores the blood flow effectively into downstream ischemic tissues. This review overviews the role of VSMC phenotypic switching in the physiological arteriogenesis process and how the VSMC phenotype is affected by the primary triggers of arteriogenesis such as blood flow hemodynamic forces and inflammation. Better understanding the role of VSMC phenotype switching during arteriogenesis can identify novel therapeutic strategies to enhance revascularization in peripheral arterial disease.

Recurrent idiopathic carotid and coronary artery vasospasm treated by stent implantations.

Arterial vasospasm is a well known cause of ischemia and, if prolonged, of parenchymal infarction. The clinical presentation varies according to the involved arterial district. We describe a rare case, which occurred in a young lady, of recurrent and multisystem vasospasm, resulting in multiple cerebral and myocardial infarctions. Our patient was resistant to medical therapy, requiring stent implantation of the involved vessels.

US Velocimetry in Participants with Aortoiliac Occlusive Disease.

Background The accurate quantification of blood flow in aortoiliac arteries is challenging but clinically relevant because local flow patterns can influence atherosclerotic disease. Purpose To investigate the feasibility and clinical application of two-dimensional blood flow quantification using high-frame-rate contrast-enhanced US (HFR-CEUS) and particle image velocimetry (PIV), or US velocimetry, in participants with aortoiliac stenosis. Materials and Methods In this prospective study, participants with a recently diagnosed aortoiliac stenosis underwent HFR-CEUS measurements of the pre- and poststenotic vessel segments (August 2018 to July 2019). Two-dimensional quantification of blood flow was achieved by performing PIV analysis, which was based on pairwise cross-correlation of the HFR-CEUS images. Visual inspection of the entire data set was performed by five observers to evaluate the ability of the technique to enable adequate visualization of blood flow. The contrast-to-background ratio and average vector correlation were calculated. In two participants who showed flow disturbances, the flow complexity and vorticity were calculated. Results Thirty-five participants (median age, 67 years; age range, 56-84 years; 22 men) were included. Visual scoring showed that flow quantification was achieved in 41 of 42 locations. In 25 locations, one or multiple issues occurred that limited optimal flow quantification, including loss of correlation during systole (n = 12), shadow regions (n = 8), a short vessel segment in the image plane (n = 7), and loss of contrast during diastole (n = 5). In the remaining 16 locations, optimal quantification was achieved. The contrast-to-background ratio was higher during systole than during diastole (11.0 ± 2.9 vs 6.9 ± 3.4, respectively; P < .001), whereas the vector correlation was lower (0.58 ± 0.21 vs 0.47 ± 0.13; P < .001). The flow complexity and vorticity were high in regions with disturbed flow. Conclusion Blood flow quantification with US velocimetry is feasible in patients with an aortoiliac stenosis, but several challenges must be overcome before implementation into clinical practice. Clinical trial registration no. NTR6980 © RSNA, 2021 Online supplemental material is available for this article.

Significance of Hall currents on hybrid nano-blood flow through an inclined artery having mild stenosis: Homotopy perturbation approach.

The rheological perspective of blood flow with the suspension of metallic or non-metallic nanoparticles through arteries having cardiovascular diseases is getting more attention due to momentous applications in obstructed hemodynamics, nano-hemodynamics, nano-pharmacology, blood purification system, treatment of hemodynamic ailments, etc. Motivated by the novel significance and research in this direction, a mathematical hemodynamics model is developed to mimic the hemodynamic features of blood flow under the concentration of hybrid nanoparticles through an inclined artery with mild stenosis in the existence of dominating electromagnetic field force, Hall currents, heat source, and porous substance. Copper (Cu) and copper oxide (CuO) nanoparticles are submerged into the blood to form hybrid nano-blood suspension (Cu-CuO/blood). The attribute of the medium porosity on the blood flow is featured by Darcy's law. The mathematical equations describing the flow are formulated and simplified under mild stenosis and small Reynolds number assumptions. To determine the analytical solution of the resulting nonlinear momentum equation, the homotopy perturbation method (HPM) is employed. Several figures are graphed to assess the hemodynamical contributions of various intricate physical parameters on blood flow phenomena through the inclined stenosed artery. Significant outcomes from graphical elucidation envisage that the hemodynamic resistance to the blood flow is reduced due to the dispersion of more hybrid nanoparticles in the blood. The hemodynamic resistance (impedance) increases approximately two times by dispersing 0.11% hybrid nanoparticles in the blood flow. The temperature of Cu-CuO/blood is found to be lower in comparison to Cu-blood and pure blood. Intensification of Hall parameter attenuates the wall shear stress at the arterial wall. The trapping phenomena are also outlined via streamline plots which exemplify the blood flow pattern in the stenosed artery under the variation of the emerging parameters. As anticipated, the addition of a large number of hybrid nanoparticles significantly modulates the blood flow pattern in the stenotic region. The novel feature of this model is the impressive impact of Hall currents on hybrid nanoparticle doped blood flow through the stenosed artery. There is another piece of significance is that HPM is the most suitable method to handle the nonlinear momentum equation under the aforementioned flow constraints. Outcomes of this simulation may be valuable for advanced study and research in biomedical engineering, bio-nanofluid mechanics, nano-pharmacodynamics.

Bilateral brachial artery infiltration by tumoral calcinosis: A case report.

We, herein, presented a rare case of bilateral brachial artery infiltration by tumoral calcinosis located on both elbows. A 58-yearold man presented with a history of painless, palpable solid mass restricting the range of motion of both elbows. These masses were located on the anterior aspect of the elbows and gradually enlarged. After clinical, laboratory and radiological examinations, tumoral calcinosis was suspected, and excisional biopsy was planned for a definite diagnosis. Surgery was first performed on the left elbow. The median nerve was found to be compressed but not infiltrated by the mass. Interestingly, the brachial artery was totally infiltrated throughout the entire mass. Occlusion was observed in the brachial artery located within the mass. The tumor on the left elbow, 8.5 × 5.5 × 2.5 cm in size, was totally excised with approximately 12-cm brachial artery segment. The artery was resected until the healthy tissue was reached. The defect was reconstructed with saphenous vein graft obtained from the ipsilateral lower extremity. The same surgical procedure was performed on the right elbow after 3 months. The tumor size on the right elbow was 7 × 3.5 × 1.7 cm. Approximately 15-cm brachial artery segment was excised, and the defect was reconstructed with saphenous vein graft. Tumoral calcinosis is a rare benign condition that can be located in close relationship with neurovascular structures. In such cases, detailed neurologic and vascular examination, including imaging modalities, for arterial flow is essential to establish a more accurate surgical plan and avoid any unexpected situation during surgery.

Acute abdominal aortic occlusion: A 16-year single-center experience.

BACKGROUND: Acute abdominal aortic occlusion (AAO) is a rare vascular emergency associated with high morbidity and mortality. In the present study, we analyzed the clinical management and outcomes for a consecutive patient series during a 16-year period. METHODS: We included all patients with an acute AAO and bilateral acute limb ischemia who had been treated between 2004 and 2019. Patients with dissection, aneurysm rupture, or chronic occlusive disease were excluded. The patient characteristics, surgical procedures, and outcomes were extracted retrospectively from a prospective aortic database, electronic patient files, and outpatient examination records. The extent of ischemia was classified according to the TASC II (Inter-Society Consensus for the Management of Peripheral Arterial Disease) section on acute limb ischemia. The primary endpoints were 30-day mortality (safety endpoint) and the combined 6-month amputation and/or death rate (efficacy endpoint). The follow-up outcomes, amputation rates, and 30-day complications were evaluated as secondary endpoints. The patient cohort was divided into four 4-year groups (2004-2007, 2008-2011, 2012-2015, 2016-2019) to assess the outcome changes over time. Statistical analysis included χ2 tests and univariate and linear regression analyses. RESULTS: A total of 74 patients (57% male; median age, 64.5 years) with an acute AAO were identified. Arterial thrombosis was the most common etiology (66%). The extent of ischemia was TASC I, IIa, IIb, and III in 7%, 39%, 40%, and 14%, respectively. The patient numbers had increased significantly over time (P = .016). Of the patients, 42% had undergone open transfemoral recanalization (including hybrid procedures), 35% open aortic surgery, 15% extra-anatomic bypass surgery, and 5% (four patients) endovascular therapy alone. The overall 30-day mortality rate was 23%, and the 6-month amputation and/or death rate was 43%. The 30-day mortality rate had declined significantly from 54% for 2004 to 2007 to 10% for 2011 to 2015 (odds ratio [OR], 0.10; 95% confidence interval [CI], 0.001-0.52) and 20% for 2016 to 2019 (OR, 0.21; 95% CI, 0.05-0.90), a statistically nonsignificant trend showing that the relative decline in the use of open aortic procedures was associated with decreased 30-day mortality (P = .06). Univariate analysis indicated that elevated serum lactate on admission (OR, 3.33; 95% CI, 1.06-10.48) and an advanced stage of limb ischemia (OR, 4.33), were strongly associated with an increased 30-day mortality rate. The incidence of severe postoperative systemic complications also indicated a greater incidence of both primary endpoints. The 6-month amputation and/or mortality rates were also affected by the presence of atrial fibrillation (OR, 3.63; 95% CI, 1.34-9.79) and increased patient age (OR, 3.96; 95% CI, 1.49-10.53). CONCLUSIONS: Acute AAO remains a life-threatening emergency. Immediate transfemoral open or endovascular techniques should be preferred, if technically possible and proper intraoperative imaging is available.

Open Thrombectomy for Acute Abdominal Aortic Occlusion Due to Tumor Embolism after Lung Resection.

Arterial tumor embolization is a rare but often catastrophic complication of lung resection for malignancy. This case describes tumor embolization to the abdominal aorta in a patient with metastatic sarcoma. After partial pneumonectomy he developed acute kidney injury, bilateral lower limb ischemia and spinal cord ischemia. Computed tomography angiogram demonstrated complete occlusion of the paravisceral aorta. Perfusion was restored with open thromboembolectomies of the abdominal aorta, superior mesenteric artery and bilateral lower limbs. For perioperative lung cancer patients with acute arterial occlusion intraluminal tumor should be considered and thereby an open approach to revascularisation adopted.

Popliteal Artery Thrombosis in a Young Patient Secondary to Proximal Tibial Osteochondroma.

Popliteal artery occlusion is mainly seen in elderly patients with late stage atherosclerotic occlusive disease. In young, nonsmoking patients, popliteal artery occlusion can be caused by a variety of other etiologies. The diagnosis is suspected clinically and confirmed with ultrasound, computed tomography angiogram (CTA) or angiography, which can also aid in understanding the underlying cause. We present a 40-year-old very active male, who developed progressive symptoms of claudication over a 4 months interval and was found to have a thrombosed popliteal artery secondary to external compression from a tibial osteochondroma. The patient was treated with in-situ saphenous vein bypass from the above knee popliteal artery to the anterior tibial artery. The bypass was widely patent at 24 months.

Computed Tomography Perfusion Deficit Volumes Predict Functional Outcome in Patients With Basilar Artery Occlusion.

Background and Purpose: Basilar artery occlusion is associated with high morbidity and mortality. Optimal imaging and treatment strategy are still controversial and prognosis estimation challenging. We, therefore, aimed to determine the predictive value of computed tomography perfusion (CTP) parameters for functional outcome in patients with basilar artery occlusion in the context of endovascular treatment. Methods: Patients with basilar artery occlusion who underwent endovascular treatment were selected from a prospectively acquired cohort. Ischemic changes were assessed with the posterior-circulation Acute Stroke Prognosis Early Computed Tomography Score on noncontrast computed tomography, computed tomography angiography (CTA) source images, and CTP maps. Basilar artery on CTA score, posterior-circulation CTA score, and posterior-circulation collateral score were evaluated on CTA. Perfusion deficit volumes were quantified on CTP maps. Good functional outcome was defined as modified Rankin Scale score ≤3 at 90 days. Statistical analysis included binary logistic regressions and receiver operating characteristics analyses. Results: Among 49 patients who matched the inclusion criteria, 24 (49.0%) achieved a good outcome. In univariate analysis, age, National Institutes of Health Stroke Scale score on admission, posterior cerebral artery involvement, absence of or hypoplastic posterior communicating arteries, basilar artery on CTA score, posterior-circulation Acute Stroke Prognosis Early Computed Tomography Score, and perfusion deficit volumes on all CTP parameter maps presented significant association with functional outcome (P<0.05). In multivariate analyses, Basilar artery on CTA score, posterior-circulation Acute Stroke Prognosis Early Computed Tomography Score (odds ratio range, 1.31­2.10 [95% CI, 1.00­7.24]), and perfusion deficit volumes on all CTP maps (odds ratio range, 0.77­0.98 [95% CI, 0.63­1.00]) remained as independent outcome predictors. Cerebral blood flow deficit volume yielded the best performance for the classification of good clinical outcome with an area under the curve of 0.92 (95% CI, 0.84­0.99). Age and admission National Institutes of Health Stroke Scale had lower discriminatory power (area under the curve, <0.7). Conclusions: CTP imaging parameters contain prognostic information for functional outcome in patients with stroke due to basilar artery occlusion and may identify patients with higher risk of disability at an early stage of hospitalization.

Quantitative laser speckle auto-inverse covariance imaging for robust estimation of blood flow.

We present a quantitative model to provide robust estimation of the decorrelation time using laser speckle auto-inverse covariance. It has the advantages of independence from the statistical sample size, speckle size, static scattering, and detector noise. We have shown cerebral blood flow imaging through an intact mouse skull using this model. Phantom experiments and two animal models, middle cerebral artery occlusion, and cortical spreading depression were used to evaluate its performance.