Comparison of open and endovascular treatments of post-carotid endarterectomy restenosis.

AIM OF THE STUDY: To compare early and long term results of open and endovascular treatment of post-carotid endarterectomy (CEA) restenosis in a single centre experience. METHODS: From January 2005 to December 2011, ninety-nine consecutive interventions for primary severe post-CEA restenosis were performed: in 41 cases (41%, Group 1) open repair was carried out, whereas the remaining 58 patients (59%, group 2) underwent an endovascular treatment. Data concerning these interventions were prospectively collected in a dedicated database containing main pre, intra and postoperative variables. Early results in terms of 30-day stroke and death rates were analysed and compared with χ(2) test. Follow-up results were analysed with Kaplan Meier curves and compared with log-rank test. RESULTS: Mean time from primary CEA was 75 months in group 1 and 42 months in group 2 (p = 0.002; 95% CI 12-52). There were no differences between the two groups in terms of demographic data, comorbidities, risk factors for atherosclerosis, preoperative clinical status or degree of stenosis on the operated side. In group 1 interventions consisted of redo-CEA in 37 patients and of carotid bypass in the remaining 4; all the patients in group 2 underwent stent placement with cerebral protection device. No perioperative deaths and ipsilateral neurological events occurred in both groups. One patient in group 1 suffered from a non-fatal acute myocardial infarction. Other six patients (14.5%) experienced transient cranial nerve injuries, with complete regression at 1-month follow-up; two patients had postoperative dysphagia due to neck haematoma, which was medically managed. Neither access-related nor systemic complications were recorded in group 2. Follow-up was available in 98% of the patients with a median duration of 24 months (range 3-72). There were no differences in terms of 4-year estimated survival and stroke-free survival, whereas patients in group 1 were more likely to develop severe (>80%) secondary restenosis (28.3% and 6.5%, respectively, p = 0.01, log rank 6.3) and to undergo secondary reintervention (22% and 11%, respectively p = 0.01, log rank 6). CONCLUSIONS: despite the selection limits and bias of this study, in our experience open and endovascular surgery provided similar perioperative results in the management of post-CEA restenosis. Long term outcomes are similar, too, despite a slight increase in secondary restenosis and recurrent reinterventions among open surgery patients, warranting further studies and analysis.

A 20-year experience with surgical management of true and false internal carotid artery aneurysms.

AIM OF THE STUDY: The aim of this study was to retrospectively analyse early and late results of surgical management of internal carotid artery (ICA) true and false aneurysms in a single-centre experience. MATERIALS AND METHODS: From January 1988 to December 2011, 50 consecutive interventions for ICA aneurismal disease were performed; interventions were performed for true ICA aneurysm in 19 cases (group 1) and for ICA post-carotid endarterectomy (CEA) pseudo-aneurysm in the remaining 31 (group 2). Early results (<30 days) were evaluated in terms of mortality, stroke and cranial nerves' injury and compared between the two groups with χ(2) test. Follow-up results (stroke free-survival, freedom from ICA thrombosis and reintervention) were analysed with Kaplan-Meier curves and compared with log-rank test. RESULTS: All the patients in group 1 had open repair of their ICA aneurysm; in group 2 open repair was performed in 30 cases, while three patients with post-CEA aneurysm without signs of infection had a covered stent placed. There were no perioperative deaths. Two major strokes occurred in group 1 and one major stroke occurred in group 2 (p = 0.1). The rates of postoperative cranial nerve injuries were 10.5% in group 1 and 13% in group 2 (p = 0.8). Median duration of follow-up was 60 months (range 1-276). Estimated 10-year stroke-free survival rates were 64% in group 1 and 37% in group 2 (p = 0.4, log rank 0.5); thrombosis-free survival at 10 years was 66% in group 1 and 34% in group 2 (p = 0.2, log rank 1.2), while the corresponding figures in terms of reintervention-free survival were 68% and 33%, respectively (p = 0.2, log rank 1.8). CONCLUSIONS: Surgical treatment of ICA aneurismal disease provided in our experience satisfactory early and long-term results, without significant differences between true and false aneurysms. In carefully selected patients with non-infected false aneurysm, the endovascular option seems to be feasible.

Urgent carotid endarterectomy in patients with recent/crescendo transient ischaemic attacks or acute stroke.

OBJECTIVES: Objective of this study was to review the results of urgent carotid endarterectomy (CEA) performed in patients with recent (< 24 h) or crescendo (at least 2 episodes in 24 h) transient ischaemic attack (TIA) or with acute stroke in a single centre experience. MATERIALS AND METHODS: From January 2000 to December 2008, 75 patients underwent urgent CEA for severe internal carotid artery stenosis and recent/crescendo TIA (51 patients, TIA group) or acute stroke (24 patients, stroke group). In patients with acute stroke the intervention was proposed on the basis of clinical and instrumental features (patient conscious, patency of middle cerebral artery, no lesions or limited brain infarction at CT scan) according to neurologists' suggestion. Data from all the interventions were prospectively collected in a dedicated database, which included main pre-, intra- and postoperative parameters. Independent neurological assessment with National Institute of Health Stroke Scale (NIHSS) score calculation was performed before the operation and within the 30th postoperative day. Early (< 30 days) results were evaluated in terms of mortality, modifications in NIHSS values and stroke and death rates. The surveillance program consisted of clinical and ultrasonographic examinations at 1, 6 and 12 months and yearly thereafter. Follow-up results (survival, occurrence of ipsilateral stroke in TIA group, recurrence of stroke in stroke group) were analysed by Kaplan-Meier curves. RESULTS: Among patients presenting with TIA, 28 had crescendo TIAs and 23 had a recent TIA; In stroke group, two patients had a stroke in evolution, eight patients had a recent major non-disabling stroke and 14 patients had a recent minor stroke. Preoperative mean value of NIHSS score in stroke group was 4.7 (SD 3.2). There were 2 perioperative (< 30 days) deaths, both in stroke group, in one case due to acute respiratory failure and to fatal stroke in the other one (preoperative NIHSS value 9, postoperative 17), with a cumulative 30-day mortality rate of 2.7%, significantly higher in stroke group (8.3%) than in TIA group (no death, p = 0.03). No postoperative cerebral haemorrhage occurred. In TIA group one postoperative major stroke occurred, with a 30-day stroke and death rate of 1.9%. In surviving patients of stroke group NIHSS value improved in 13 cases, with a mean improvement of 2 points (SD 0.9); in 8 cases the value remained unchanged, while in the remaining case it increased from 2 to 4. Mean postoperative NIHSS score in stroke group was 3.9 (SD 3.7), significantly reduced in comparison with preoperative value (p < 0.001). Mean duration of follow-up was 34 months (SD 28.1). No ipsilateral stroke in patients of TIA group occurred; in stroke group a recurrent fatal stroke at 1 postoperative month was recorded. Estimated 48-month stroke-free survival rate TIA group was 95% and 79% in stroke group (p = 0.02). CONCLUSIONS: Urgent CEA in patients with recent/crescendo TIA provided in our experience excellent results, with low rates of perioperative and late stroke. In selected patients with acute stroke early surgery seems to provide acceptable results.

Below-knee revascularization in patients with critical limb ischemia: long-term comparison of redo vs primary interventions.

AIM: The aim of this study was to evaluate the authors' experience in below-knee revascularization in patients with critical limb ischemia, comparing long-term outcomes in primary and secondary interventions. METHODS: From January 2000 to December 2006, 140 consecutive below-knee revascularizations in patients with critical limb ischemia were performed at the Department of Vascular Surgery of the University of Florence (Italy). In 105 patients (75%) a primary intervention was performed (Group 1). Early and long-term results in terms of survival, patency and limb salvage were compared with those obtained in the remaining 35 patients (25%) secondarily operated on in the same period for a late (>30 days) bypass graft thrombosis (Group 2). RESULTS: One patient died in the early postoperative period. Thirty-day thrombosis and amputation rates were poorer in Group 2 than in Group 1 (17.1% and 4.8%, P=0.02; 37.1% and 16.2%, P=0.01, respectively). Mean duration of follow-up was 25.1 months. At 60 months there were no differences between the two groups in terms of survival (90.1% in Group 1 and 90.9% in Group 2; P=NS), primary patency (43.5% in Group 1 and 31.9% in Group 2; P=NS) and secondary patency (48.4% in Group 1 vs 43.8% in Group 2; P=NS). Estimated 60-month limb salvage rate was significantly poorer in Group 2 than in Group 1 (64.1% and 77.7%, respectively; P=0.05). In Group 2 prosthetic graft material significantly affects 60-month limb salvage rate. CONCLUSION: Redo below-knee revascularization in patients with critical limb ischemia provides acceptable long-term results in terms of primary and secondary patency; however, limb salvage appeared to be slightly worse in patients undergone redo surgery.

The treatment of isolated iliac artery aneurysm in patients with non-aneurysmal aorta.

OBJECTIVES: The aim of the study was to evaluate early and mid-term results of surgical repair of isolated iliac artery aneurysm (IAA) in patients with non aneurysmal abdominal aorta. METHODS: From January 1996 to December 2006, 34 patients with IAA had elective surgery. In 32 cases open repair was performed. Two patients had endovascular repair using a tube endoprosthesis and internal iliac artery coil embolization. The diameters of the abdominal aorta and iliac arteries were measured preoperatively and during follow-up. Early and late results in terms of mortality, major morbidity, reinterventions and graft-related complications were recorded. Mean pre and postoperative diameters of abdominal aorta were compared. RESULTS: The site of the IAA was the common iliac artery in 29 cases (10 bilateral), internal iliac artery in 4 cases and external iliac artery in 1 case. Preoperative mean abdominal aortic diameter was 22.2mm (SD 7.6). There were no perioperative deaths and two major complications (retroperitoneal bleeding and limb ischemia) occurred. At the median follow-up time of 24 months survival was estimated as 91%. No reinterventions, graft thrombosis and graft related complications occurred. There were no cases of abdominal aorta aneurysm development. Mean aortic diameter at the most recent imaging was 23.1mm, which was not significantly different from preoperative values (p=0.2). CONCLUSIONS: Surgical treatment of IAAs provides good early and mid-term results. During mid-term follow-up the diameter of abdominal aorta remains stable, suggesting IAA may be a localized aneurysmal disease.

[Volume increase of the left leg and dyspnea as clinical manifestation of ruptured abdominal aorta aneurysm: problems of diagnostic assessment]. / Aumento di volume dell'arto inferiore sinistro e dispnea come presentazione clinica di rottura di aneurisma dell'aorta addominale: problemi di inquadramento diagnostico.

The case of a 74-year-old man who presented with abdominal pain, worsening dyspnea and swelling of the left lower limb is described. Careful history taking and clinical examination enabled diagnosis of the rupture of an abdominal aortic aneurysm.

[Role of local and regional thrombolysis in late thromboses of the branches of prostheses]. / Le rôle de la thrombolyse loco-régionale dans les thromboses tardives des branches de prothèses.

Results of treatment of a personal series of 12 patients developing a thrombus in branches of prostheses after aorto-iliac surgery are presented. A therapeutic procedure used over the last two years consists of initial local and regional thrombolysis to remove the acute obstruction, followed by surgery at the level chosen, and if necessary to correct a faulty technique or progression of the atherosclerosis. Good results were obtained even for thrombosis originating after the conventional 8-10 day postoperative period, insofar as the thrombus that develops in a graft may differ from one forming in an artery. This aspect requires further studies, which will also provide greater clarification of the etiopathogenicity.