Off the Shelf Thoracic Endovascular Aortic Repair with Sandwich Technique for the Treatment of a Thoraco-Abdominal Penetrating Aortic Ulcer.

Introduction: Penetrating aortic ulcers (PAUs) are the rarest subset of acute aortic syndromes, and a thoraco-abdominal (TA) location is uncommon. Endovascular surgery is considered first line treatment. Custom made branched/fenestrated endografts have been successfully applied in this disease but are unavailable in the urgent setting. Off the shelf solutions may be required in high risk patients. The case of a symptomatic rapidly expanding TA-PAU without a distal seal zone that underwent urgent endovascular repair is described. Report: An 81 year old male presented with acute intense thoracic pain. Workup revealed a large TA-PAU. As pain was refractory and computed tomography angiography confirmed rapid expansion, urgent repair was proposed. Due to multiple comorbidities and absence of adequate distal seal zone, an off label endovascular treatment was proposed. The patient underwent successful endovascular repair with two aortic stent grafts (GORE cTAG) with 30% oversize and 50-55 mm overlap between modules, combined with chimney self expanding stent grafts (GORE VIABAHN) to the coeliac trunk and superior mesenteric artery in a sandwich configuration. The post-operative course was uneventful. Follow up at 18 months revealed no endoleaks and patent bridging stent grafts without visceral compromise. Discussion: Thoracic endovascular aortic repair (TEVAR) is considered the first treatment option for urgent PAU. However, anatomic requirements limit its use in the thoraco-abdominal aorta. Parallel graft techniques have been described to overcome these anatomic constraints in TA aneurysms. The use of a "sandwich technique" to successfully exclude a PAU without a distal sealing zone for standard TEVAR is described. The advantage was limited aortic coverage compared with a branched device or an "octopus" technique. This solution is particularly useful in urgent situations when patients cannot wait for a custom made device and the morbidity associated with open or hybrid repair is unacceptably high. An off the shelf sandwich technique is a potential safe and long lasting therapeutic option for the urgent treatment of TA-PAU.

Paclitaxel in real-life data is not associated with reduced survival but has limited benefit in preventing amputation.

BACKGROUND: Recent meta-analysis of randomized-controlled trials reported an increased risk of long-term mortality in patients treated with paclitaxel-coated devices (PCD) for femoropopliteal arteries (FP) lesions. However, real-life data on the subject is contradictory and data from CLTI patients is missing. The authors aim to evaluate the impact of PCD for the treatment of FP lesions on long-term mortality and amputation on a real-life cohort up to 5 years. METHODS: All patients treated for FP lesions with endovascular devices from January 2013 to December 2016 were included, irrespective of clinical presentation. Primary endpoint is overall survival. Secondary endpoints are freedom-from major amputation and amputation-free survival. Survival estimates were obtained using Kaplan-Meier plots and a multivariable model was constructed to correct for relevant baseline differences. RESULTS: From 2013 to 2016, 351 patients with FP lesions were treated, 250 with uncoated devices (nPCD) and 101 with PCD. Patients treated with nPCD were significantly older, more often female and with more severe degrees of ischemia. Median follow-up was 55(20-71) months. Overall survival and amputation-free survival were significantly higher in patients treated with PCD. Survival at one-year was 79% vs. 92%, at two-years 69% vs. 79% and at five-years 50% vs. 65% (P=0.02). AFS was 43% vs. 57% at 5-years (P=0.016). Freedom-from major amputation was similar between groups. After correction for relevant baseline differences on multivariable analysis, the survival advantage for patients treated with PCD was lost at 2 and 5 years. CONCLUSIONS: Our results do not confirm the findings of increased mortality associated with PCD. However, no improvement in amputation rate was found. For the time, our institutional data does not support withholding PCD to reduce mortality but suggests that the benefit in preventing amputation is not significant.

Total Luminal Volume Predicts Risk after Endovascular Aneurysm Repair.

OBJECTIVE: Large aneurysm diameter represents a well known predictor of late complications after endovascular aneurysm repair (EVAR). However, the role of the thrombus free lumen inside the abdominal aortic aneurysm (AAA) sac is not clear. It was hypothesised that greater luminal volume represents a relevant risk factor for late complications after EVAR. METHODS: A retrospective cohort analysis was performed including all patients undergoing EVAR from 2005 to 2016 at a tertiary referral institution. Pre-operative AAA lumen volume was measured in centre lumen line reconstructions and patients were stratified into quartiles according to luminal volume. The primary endpoint was freedom from AAA related complications. Secondary endpoints were freedom from neck events (type 1A endoleak, migration >5 mm or any pre-emptive neck related intervention), iliac related events (type 1B endoleak or pre-emptive iliac related intervention), and overall survival. RESULTS: Four hundred and four patients were included: 101 in the first quartile (Q1; <61 cm3). Patients with higher luminal volumes had wider, shorter, and more angulated proximal necks. There were more ruptured AAAs, more aorto-uni-iliac implanted devices and patients outside neck instructions for use in the 4th quartile. Five year freedom from AAA related complications was 79%, 66%, 58% and 56%, respectively (p = .007). At five years, freedom from neck related events was 86%, 84%, 73%, and 71%, respectively, for the four groups (p = .009), and freedom from iliac related events was 96%, 91%, 88%, and 88%, respectively (p = .335). On multivariable analysis, luminal volume was an independent predictor of late complications (Q4 vs. Q1 - hazard ratio: 1.91, 95% confidence interval 1.01-3.6, p = .046). Overall survival at five years was not affected by lumen volume (p = .75). CONCLUSION: AAA luminal volume represents an important risk factor for AAA related complications. This information may be considered when deciding tailoring surveillance protocols after EVAR. However, larger studies are needed to validate this hypothesis.

Vascular Trauma in Children-Review from a Major Paediatric Center.

BACKGROUND: Traumatic noniatrogenic vascular injuries in children are rare and rarely discussed in literature. Pediatric vascular injuries pose a set of challenges mainly because of continued growth and development in a child or adolescent. The purpose of the study is to characterize management strategies and outcomes in these cases. METHODS: This is a single-center retrospective review of patients less than age 18 years (pediatric age) with acute, noniatrogenic traumatic vascular injuries between January 2009 and December 2015. Patient's demographics, injury characteristics, surgical management, complications, and follow-up were analyzed. RESULTS: From 2009 to 2015, 3277 children with traumatic injuries were treated, of which 21 (0.6%) had 23 significant vascular injuries: 17 arterial and 6 venous injuries. The majority were males (n = 16), and the median age was 14 years (range 1 to 16 years). Penetrating injuries were the predominant mechanism (n = 21), mainly by glass (n = 13). At presentation, 4 patients were hemodynamically unstable, 3 of them in hypovolemic shock. All patients were managed operatively. Operations for arterial injuries included 5 primary arterial repairs, 4 repairs using vein grafts and 8 ligations. The following adjunct procedures were necessary: one 4-compartment leg fasciotomy due to associated soft tissue trauma, 8 tendon repairs, and 11 nerve repairs. Operations for venous injuries included 4 ligations and 2 primary repairs. There were no intraoperative or postoperative deaths, major complications, or limb loss. The median length of stay in the hospital was 6 days (range: 2-23 days). The median time of follow-up was 52 months (range: 20-94 months). Ten patients did not have any sequelae, and 11 patients reported impaired mobility and/or decreased sensation, which was transitory in most cases and related to associated neurological or muscle tendon injuries. All reconstructions remained patent over the course of follow-up. No limb asymmetry was observed. CONCLUSIONS: Noniatrogenic pediatric vascular trauma is uncommon. Penetrating mechanism is more common than blunt and extremities are more frequently affected. Overall complications come from associated injuries to tendons and nerves.