Role of Hemodynamic Assessment and Limitations in Ankle-Brachial Pressure Index, Toe- Brachial Pressure Index to Predict Wound Healing After Revascularization.

Chronic limb-threatening ischemia (CLTI) represents one of the most severe forms of peripheral arterial disease implying impaired wound healing and tissue loss at the same time posing a significant impact on the quality of life of patients and a serious economic burden on healthcare systems around the world. A major challenge in the management of patients with CLTI is the validity and role of non-invasive hemodynamic parameters in assessing their clinical status before and after revascularization. Traditionally, the diagnosis of CLTI is routinely based on clinical symptoms and confirmed by measurements of non-invasive limb hemodynamics including ankle-brachial pressure index (ABPI) and toe-brachial pressure index (TBPI). However, whether these indices alone can provide definitive treatment or be used as adjunctive tool along with the implementation of novel techniques to help guide revascularization for CLI patients still remains unclear.

Open Management of an Asymptomatic 4.2 Cm Middle Colic Artery Aneurysm and Liteture Review.

BACKGROUND: Aneurysms of the middle colic artery (MCAA) and its branches are exceedingly rare accounting for <3% of total visceral aneurysms. Very few MCAA cases have been reported in the literature with only three cases accounting for a diameter >4 cm. METHOD: We describe the successful open repair with ligation of a 4.2 cm asymptomatic MCAA in a female patient through the gastrohepatic ligament taking meticulous caution to avoid injury of the pancreas. The postoperative period was uneventful and the patient was discharged from the hospital on the fifth postoperative day. At 1 month follow-up the postoperative computed tomographic angiography documented complete exclusion of the MCAA and absence of contrast agent in the sac both in the arterial and the venous phase. CONCLUSION: While the endovascular treatment is the first-line option for visceral aneurysms, the open approach is still reserved for certain cases of hostile anatomy, challenging location and large size. Our case highlights the irreplaceable role of open surgery and underlines the collaboration between surgical specialties.

An asymptomatic double aortic arch with separate right vertebral artery and left subclavian artery originating from Kommerell Diverticulum combined with congenital asplenia and absence of celiac trunk.

This report describes the unique case of a completely patent Double Aortic Arch (DAA) combined with Kommerell Diverticulum (KD), absence of celiac trunk and congenital asplenia. The anatomical variants described were identified and assessed in a 51-year old female from a computed-tomography angiography (CTA) images with 3D-volume rendered reconstructions during her follow-up after hysterectomy. The reconstructed CTA images showed a DAA with the left common carotid artery stemming from the hypoplastic left aortic arch while the left subclavian artery originated from a KD in the descending thoracic aorta. A symmetric arrangement of the aortic arch branches was demonstrated, comprising a full vascular ring. Since the patient had been completely asymptomatic and with no symptoms of compression of the esophagus or trachea, no surgical management was advised. The abdomen CTA imaging revealed absence of the celiac trunk with direct origin of the common hepatic and the left gastric artery from the superior mesenteric artery as well as asplenia. We presented a case of asymptomatic DAA of completely patent arches with the right vertebral artery branching separately of and the left SCA originating from KD in the descending aorta. The term KD can be identified also in other arch anomalies than the one originally described. Since anatomical anomalies can be frequently combined, thorough imaging inspection with CTA of both thorax and abdomen is suggested.

Tips and Tricks to Facilitate the Combined Iliofemoral Endarterectomy With Stenting for Heavily Calcified Common Femoral Artery Atherosclerosis With Involvement of the External Iliac Artery.

BACKGROUND: Management of a heavily calcified atherosclerotic occlusive disease involving the common femoral artery (CFA) and external iliac artery (EIA), poses a surgical challenge. Though the current guidelines recommend open surgical therapy for such lesions, this approach is neither easy nor represents the current real-life practice. PURPOSE: To describe tips and tricks facilitating the hybrid technique for the management of distal iliofemoral atherosclerotic disease, where classic endarterectomy is inadequate or ill-performed. TECHNIQUE: A contralateraly inserted guidewire reaches the distal iliac artery via the crossover technique and is directly retrieved from the femoral arteriotomy immediately after removal of the anterior plaque segment. The retrieved and secured guidewire enables extensive retrograde CFA endarterectomy over the wire with avusion proximally to the inguinal ligement, followed by patch arterioplasty. Externalizing the guidewire from the patch enables traction on it and facilitates advancement of the stent through tortuous or stenosed iliac vessels as well as accurate stent deployment to cover the margin of the EIA residual plaque. Moreover, this manipulation enables ipsilateral placement of a sheath and passage of a second, retrograde guidewire to perform kissing stenting in the common iliac vessels. Chronic thrombotic lesions require covered stents to avoid thrombus propagation and meticulous flushing before completion of the femoral patching. CONCLUSIONS: The combined iliofemoral endarterectomy with stenting does not require advanced endovascular skills and prevents complications associated with incomplete femoral endarterectomy. Extensive avulsion endarterectomy proximal to the inguinal ligament is efficiently and safely performed over a retrieved crossover guidewire, enabling precise residual stenting above the flexion site.

Promising Novel Therapies in the Treatment of Aortic and Visceral Aneurysms.

Aortic and visceral aneurysms affect large arterial vessels, including the thoracic and abdominal aorta, as well as visceral arterial branches, such as the splenic, hepatic, and mesenteric arteries, respectively. Although these clinical entities have not been equally researched, it seems that they might share certain common pathophysiological changes and molecular mechanisms. The yet limited published data, with regard to newly designed, novel therapies, could serve as a nidus for the evaluation and potential implementation of such treatments in large artery aneurysms. In both animal models and clinical trials, various novel treatments have been employed in an attempt to not only reduce the complications of the already implemented modalities, through manufacturing of more durable materials, but also to regenerate or replace affected tissues themselves. Cellular populations like stem and differentiated vascular cell types, large diameter tissue-engineered vascular grafts (TEVGs), and various molecules and biological factors that might target aspects of the pathophysiological process, including cell-adhesion stabilizers, metalloproteinase inhibitors, and miRNAs, could potentially contribute significantly to the treatment of these types of aneurysms. In this narrative review, we sought to collect and present relevant evidence in the literature, in an effort to unveil promising biological therapies, possibly applicable to the treatment of aortic aneurysms, both thoracic and abdominal, as well as visceral aneurysms.

Teaching vascular anatomy: the anatomy we know, the anatomy we see or the anatomy we need?

PURPOSE: This article presents the evolution of the subject of vascular anatomy and discusses the associated clinical applicability. METHODS: Clinically-driven surgical examples met in our everyday practice were used to depict characteristic anatomical paradoxes raised by the inconsistencies between classical anatomical perception, current imaging modalities and modern surgical techniques. RESULTS: Consequent anatomy-driven modifications of medical devices comprise a characteristic example of the vivid, modern and meaningful role that anatomy can have on clinical decision-making and improvement of technical and clinical success. Clinical experience provides a feedback that shifts the focus of anatomic research towards new fields of interest, such as the role of arterial collateral networks as therapeutic targets. The clinical feedback brings into light queries and issues where traditional anatomical answers may be vague and inadequate to apply, thereby necessitating further research, refinement and reevaluation. CONCLUSION: While the traditional teaching of vascular anatomy is based on information and illustrations derived from dissection and prosection courses, the development of modern imaging technologies applied in large numbers of living patients and application of minimally invasive techniques challenge our understanding of what should be perceived as fixed and permanent. Moreover, the recently introduced evidence-based philosophy in anatomy elaborate more robust data which not only update, validate and enrich the existing knowledge of anatomical variations but also enable subgroup analyses with respect to race, age and sex, identifying specific anatomic features associated with a significant impact on patient treatment.

Current knowledge and contemporary management of non-A non-B aortic dissections.

Non-A non-B aortic dissection (AAD) is an infrequently documented condition, comprising of only a small proportion of all AADs. The unique anatomy of the aortic arch and the failure of the existing classifications to adequately define individuals with non-A non-B AAD, have led to an ongoing controversy around the topic. It seems that the clinical progression of acute non-A non-B AAD diverges from the typical type A and B dissections, frequently leading to serious complications and thus mandating early intervention. Currently, the available treatment methods in the surgical armamentarium are conventional open, endovascular techniques and combined hybrid methods. The optimum approach is tailored in every individual case and may be determined by the dissection's location, extent, the aortic diameter, the associated complications and the patient's status. The management of non-A non-B dissections still remains challenging and a unanimous consensus defining the gold standard treatment has yet to be reached. In an attempt to provide further insight into this perplexing entity, we performed a minireview of the literature, aiming to elucidate the epidemiology, clinical course and the optimal treatment modality.

Long-term outcomes of thoracic endovascular aortic repair for the treatment of descending thoracic aortic aneurysms: a systematic review and meta-analysis.

INTRODUCTION: We undertook a systematic review of the currently published literature on TEVAR for DTAAs and we combined the eligible studies into a meta-analysis with the intention of evaluating the efficacy and the long-term durability of this treatment option. EVIDENCE ACQUISITION: A systematic search of the literature from January 2015 up to December 2022 was performed according to the PRISMA (preferred reporting items for systematic reviews and meta-analyses) guidelines. For events during follow up we calculated the incidence rates (IRs) with 95% confidence intervals (95% CIs) per 100 patient-years (p-ys) as the number of patients with outcome events occurring during the specific time period divided by the total number of p-ys. EVIDENCE SYNTHESIS: A total of 4127 study titles were identified by the initial search strategy, of which 12 were considered eligible for inclusion in the meta-analysis. A Total of 1976 patients (62% male) were identified among the eligible studies. One-year survival was 90.1% (95% CI 86.3% to 93.0%), 3-year survival was estimated at 80.5% (95% CI 69.2% to 88.4%) and the 5-year survival was estimated at 73.2% (95%CI 64.3% to 80.5%) with significant heterogeneity among studies regarding these outcomes. Regarding freedom from reintervention analysis for 1 year and 5 years was 96.5% (95% CI 94.5% to 97.8%) and 85.4% (95% CI 56.7% to 96.3%) respectively. The pooled late complications IR per 100 p-ys was 55.0 (95% CI 39.1 to 70.9), whereas the pooled IR for late reinterventions per 100 p-ys was 21.2 (95% CI 26.0 to 87.5). Late type I endoleak was reported with a pooled IR of 26.7 per 100 p-ys (95% CI 19.8 to 33.6) and late type III endoleak with a pooled IR of 7.6 per 100 p-ys (95% CI 5.5 to 9.7). CONCLUSIONS: TEVAR presents a safe and feasible solution for the treatment of DTAA with sustained long-term effectivity. Current evidence supports a satisfactory 5-year survival with low rates of reinterventions.

Long-term outcomes of the Endurant endograft in patients undergoing endovascular abdominal aortic aneurysm repair.

OBJECTIVE/BACKGROUND: To investigate the long-term outcomes after endovascular aneurysm repair (EVAR) in a real-world setting using the Endurant endograft (EG). METHODS: 184 EVAR candidates treated with the Endurant family EGs in a single vascular center were prospectively enrolled from January 2009 to December 2016. Kaplan-Meir estimates of long-term standardized primary and secondary outcome measures were performed. Per protocol, subgroup comparison analysis was performed in three groups: patients treated within instructions for use (in-IFU) vs patients treated outside IFU (outside-IFU), EVAR in patients receiving the Endurant proximal diameter 32 or 36 mm EG vs those receiving the <32 mm diameter EG and EVAR with various Endurant EG versions. RESULTS: The mean follow-up was 75.09 ± 37.9 months (range: 4.1-172 months). The median age of the patients was 72.96 ± 7.03 years (range: 55-88 years). A total of 177 patients were male (96.2%). Compliance with IFU was followed in 107 patients (58.2%). Overall survival was 69.5% and 48% at 5 and 8 years, respectively. Of the 102 all-cause deaths, 7 (6.9%) were aneurysm related. Six of these postimplant deaths occurred in patients presented with aneurysm rupture from type Ia or/and type Ib endoleak. At 5, 8, and 10 years of observation, freedom from aneurysm rupture, open surgical conversion, type I/III endoleak, any type of endoleak, aneurysm-related secondary intervention probabilities, and neck-related events were as follows: 98.1%, 95%, and 89.4%; 95.1%, 91.2%, and 85.7%; 93.6%, 87.3%, and 83.9%; 83.4%, 74%, and 70.9%; 89.8%, 76.7%, and 72%; and 96.3%, 90%, and 87.6%, respectively. Corresponding clinical success was 90%, 77.4%, and 68.4%, respectively. Patients treated outside-IFU had significantly higher risk of aneurysm rupture, open surgical conversion probability, occurrence of type I/III endoleak, and chance of reinterventions and lower clinical success probabilities compared with the in-IFU counterparts at 5 and 8 years. This statistical difference remained when type Ia endoleak or endoleak of any type was considered independently. In addition, it was stronger in patients having extreme anatomic boundaries (>1 hostile anatomic condition), when aneurysm-related death, aneurysm rupture, and clinical success at 5 years were considered. Overall proximal migration and limb occlusion were recorded in 1.1% and 4.9% of the patients, respectively. Overall reintervention rate was 17.4%. An increase in aneurysm sac diameter was observed in 12.5% of patients and was not related to IFU status. The Endurant version or the proximal EG diameter had no significant association with the chance of any complication or adverse event. CONCLUSIONS: The data confirmed the durability of the Endurant EG, achieving promising long-term outcomes in a real-world setting. However, its positive performance must be interpreted with caution in patients treated off-label especially those with extreme anatomic boundaries. In this cohort, some of EVAR advantages might be lost in the late future. Further similar studies are warranted.

Sheath-Based Combined Foam Sclerotherapy to Promote Management of Extensive Insufficiency of the Great Saphenous Vein in Venous Ulcers.

Background: Foam sclerotherapy is considered an acceptable method to treat great saphenous vein (GSV) insufficiency, promoting occlusion of its trunk and eradicating reflux. Various modalities and techniques have been described, varying form foam infusion through multiple short cannulae along the GSV to catheter-directed techniques in order to facilitate complete proximal GSV occlusion and improve technical and clinical success. Purpose: To present a modification of the sclerotherapy tehcnique where the presence of venous ulcers poses an extra challenge to the treatment of GSV treatment. Technique: We describe a technical proposal of single foam perfusion through a 11 cm 5F sheath placed at the knee level combined with simultaneous retrograde infusion below the knee. Perivenous tumescent segmental infiltration with cold normal saline at 4°C is applied initially to reduce the diameter in those GSV >6-7 mm. Conclusions: This combination avoids multiple vein cannulation in the GSV along the thigh as well as the need for antegrade infusion when GSV cannulation at the lower tibia is prohibited by a large ulcer area.

Customizing foam sclerotherapy of the great saphenous vein: A proposed algorithm to enhance technical efficacy.

OBJECTIVES: The catheter-directed foam sclerotherapy (FS) and the suggested perivenous tumescent application for great saphenous vein (GSV) diameter reduction are suggested to improve technical and clinical results; yet, their use is reported rather indiscriminately. Our aim is to introduce an algorithm categorising the use of technical modalities accompanying ultrasound-guided FS of the GSV and present the technical efficacy of FS through a 5 F × 11  cm sheath placed at the knee level. METHODS: Representative cases of GSV insufficiency were chosen to describe our methodology. RESULTS: Sole sheath-directed FS can achieve complete GSV occlusion proximally at a level comparable to the catheter-directed technique. We apply perivenous 4°C cold tumescent to GSV >6 mm even in the standing position to ensure diameter reduction of the proximal GSV as close to the saphenofemoral junction. We use long catheters only to overcome large varicosities above the knee level that could otherwise compromise the adequate foam infusion from the sheath tip. When GSV insufficiency extends along the entire limb and severe skin lesions preclude the antegrade distal catheterisation, the sheath-directed FS in the thigh can be concomitantly combined with retrograde FS from catheterisation just below the knee. CONCLUSIONS: A topology-oriented methodology with sheath-directed FS is technically feasible and avoids indiscriminate use of more complex modalities.

Technical Characteristics of the Ovation Alto for the Treatment of Abdominal Aortic Aneurysms: Application to Challenging Anatomies.

The Ovation Alto design repositions the maximum diameter of the proximal sealing ring at 7 mm below the lowermost renal artery. Although it has been introduced to address abdominal aortic aneurysms with short necks ≥7 mm, we present further applications of Alto in other neck irregularities, presenting four representative challenging cases with a short, wide, and conical neck, as well a juxtarenal aneurysm. At 1-month follow-up, there was 100% technical and clinical success.

Anterior Tibial to Dorsalis Pedis Bypass to Manage Acute Ischemia Attributed to Pilon Fracture.

Pilon fractures of the distal tibia are usually the result of a high-energy trauma and can affect seriously the arterial vasculature carrying an increased risk of amputation at the malleolar level or higher. Such cases represent a challenge for the orthopedic surgeons and a multidisciplinary approach is mandatory in order to salvage the threatened limb. We present an unusual case of a closed pilon fracture with injury of all tibial vessels leading to acute limb threatening ischemia. The patient was treated successfully with external fixation and a short tibial-pedal bypass with use of an autologous reversed saphenous vein graft. This example dictates how a distal leg fracture can be dramatic and that awareness of vascular examination coupled with high suspicion of vascular damage can be limb-saving. Multidisciplinary approach is warranted since the topology and complexity of the ankle lesions necessitate staged orthopedic reconstructions with tibio-distal bypass and appropriate skin coverage of the distal anastomosis.

Dolichoarteriopathy of Common Carotid Artery: An Unusual Entity.

Dolichoarterial disease of the carotid arteries refers to elongated arteries with tortuous, coiling, and kinking anatomy. This morphology is usually met in the elderly and not associated with atherosclerotic risk factors. Current practice reserves surgical correction only in symptomatic patients. Significant tortuosity index may be associated with stroke and poses extra difficulties to the endovascular passage of guidewires and catheters for the treatment of extra- and intracranial vascular lesions. This article presents a typical case of bilateral dolichoarteriopathy of the common carotid artery and stresses the need for further categorization of the particular morphology based on modern angiography techniques and three-dimensional reconstruction software.

The Altura endograft system for endovascular aneurysm repair: presentation of its unique design with clinical implications.

INTRODUCTION: The Altura aortic endograft for the treatment of abdominal aortic aneurysms (AAA) consists of two separate components with a proximal double D-shaped design. The braided endoskeleton of the endograft is attached only at the proximal and distal ends of the inner surface of the fabric resulting in adjustable length of the Altura components. To ensure optimal orientation and sealing, the design of Altura permits collapse, readjustment, and deployment of the repositioned D-shaped endografts. AREAS COVERED: Since this new endograft design by Lombard presents unique characteristics, the aim of this article is to present its unique structure and deployment method and discuss its applicability, indications and associated concerns. EXPERT OPINION: The Altura endograft revolutionizes the mechanism of infrarenal sealing by containing no main body at all. This feature allows ideal treatment of AAA with considerable offset of the renal arteries and permits also relining in cases of failing endografts or in cases where the short length of existing structures precludes deployment of conventional bifurcated endografts.

First case of relining an aortic bifurcated bypass graft with the Altura endograft to treat anastomotic aneurysms.

OBJECTIVE: Use of classic bifurcated endografts for relining of bifurcated aortic bypass grafts with aneurysms is usually precluded by the short distance between the lowermost renal artery and the aneurysmatic bifurcation, rendering their management challenging. METHODS: We present the use of the Altura endograft in a case of a 75-year old male with large anastomotic aneurysms in the proximal and the left iliac amastomosis of a bifurcated aortic bypass graft. The Altura endograft consists of two separate components with a proximal D-shaped design. Its braided nitinol endoskeleton is attached only at the proximal and distal ends of the inner surface of the polyester fabric and results in adjustable lengths of the components according to the vessel diameters where they are deployed. RESULTS: A 24 mm Altura sealed successfully at the native infarenal aortic segment covering the entire distance between the lowermost renal artery and the upper end of external iliac artery, providing successful exclusion of the aneurysms. No iliac extensions were used. The completion angiography showed no endoleaks. CONCLUSIONS: The unique design of Altura makes it ideal for treatment of anastomotic aneurysms of bifurcated bypass grafts, overcoming anatomic limitations. To the best of our knowledge, this is the first report addressing this crucial issue.

Guessing the sequence of multiple relinings with AFX and nitinol-based cuff: "A riddle, wrapped in a mystery, inside an enigma".

OBJECTIVE: Knowing the structural and technical features of both the older and newer aortic endografts is an essential tool to understand off-the-shelf combinations of different devices used to treat challenging abdominal aortic aneurysm (AAA) anatomies or failures of previous endovascular aneurysm repairs (EVAR). METHODS: We present a case of a 72-year-old male with history of AAA and evidence of multiple past EVAR interventions who presented with abdominal pain. With no reliable surgical history, we attempted to delineate the types of different endograft parts implanted and the sequence of relining procedure based on plain X-ray projections and combined computed tomography along with intraoperative angiography. RESULTS: A tubular endograft was presented with a distal fracture of its endoskeleton, and relined with the same type unibody bifurcate. The latter was extended proximally with an AFX extension of a characteristic radiopaque continuous rim. Angiographic findings intraoperatively excluded the latter as part of the initial procedure. Moreover, an extra nitinol-based cuff was identified centrally. CONCLUSION: In diagnostic challenges involving multiple relining attempts of different endograft parts, careful analysis of the imaging findings, based on knowledge of the structural and technical features of both the older and newer endografts is necessary for proper diagnosis, identification of potential problems and complications and intervention planning, if needed.

Foam sclerotherapy of great saphenous vein: The need for further improvement and ill-defined issues.

Foam sclerotherapy is considered an acceptable method to treat great saphenous vein (GSV) insufficiency, promoting occlusion of its trunk and eradicating reflux. Yet, certain technical points have not been standardized while issues regarding the ultrasonographic appearance of successful or acceptable GSV obliteration or the end-points of the method are not clearly defined. This article comments on the aforementioned using examples based on personal experience.