Postimplantation syndrome after endovascular aortic repair using the Anaconda™ endograft.

BACKGROUND: We report our retrospective experience on postimplantation syndrome (PIS) after the use of Anaconda™ endograft in patients undergoing elective endovascular repair of abdominal aortic aneurysms (EVAR). METHODS: Data of all patients undergoing elective EVAR between May 2000 and June 2013 using the Anaconda endograft were retrospectively reviewed and the outcomes were analyzed. Preoperative and intraoperative data, any early postoperative complications, length of in-hospital stay, incidence of PIS, and long-term complications were recorded in a database. Patients' quality of life (QOL) was also assessed at 1 month after the procedure. Statistical analysis was performed and P values ≤0.05 were considered statistically significant. Chi-squared tests, log-rank tests, Wilcoxon tests, and Kaplan-Meier survival analysis were performed as appropriate. RESULTS: Between May 2000 and June 2013, 118 patients (8 female, 6.7%) underwent elective EVAR using the Anaconda endograft. Primary success was obtained in 117 cases (99.1%). Patients were divided into 2 groups based on either the occurrence of PIS (group A: 24 patients, 20.3%) or not (group B). The length of the procedure and the in-hospital stay were longer for group A. One patient from group B died on second postoperative day from myocardial infarction (0.8%). Mean follow-up was 48.4 months (range 5-162 months). Seven endoleaks occurred in the long term regardless of the development of PIS. We did not find any correlation between the presence of PIS and the occurrence of long-term complications, but PIS was correlated to the preoperative burden of thrombus of the aneurysmal sac. On the other side, analysis of QOL surveys showed that patients who had PIS after surgery felt significantly more limited in carrying out their daily physical activities and were more emotionally discouraged and depressed/anxious about their state of health than the group that did not have PIS. CONCLUSIONS: In our experience, the occurrence of PIS was related to the duration of the procedure and the preoperative burden of thrombus of the aneurysmal sac. Overall, PIS was a benign complication after EVAR using the Anaconda endograft. However, it affected significantly the length of the in-hospital stay. Moreover, patients who had PIS after surgery felt significantly more limited in carrying out their daily physical activities and were more emotionally discouraged and depressed/anxious about their state of health than the group that did not have PIS.

Early experience with Ovation endograft system in abdominal aortic disease.

OBJECTIVE: We describe our initial experience with the use of the TriVascular Ovation endograft system for the treatment of abdominal aortic aneurysms (AAA). METHODS: We retrospectively reviewed data from patients treated for AAA using the Ovation endograft at two institutions from January 2011 to September 2012. Main outcomes included primary success, survival, complications, and device-related events. The mean follow-up period was 10 months (range 1-22 months). RESULTS: Thirty-seven patients (male: 95%, mean age: 76 yr) were treated for AAA (mean diameter: 54 mm) with the Ovation endograft. Local or regional anesthesia was used in 86.5% of cases. Percutaneous access was utilized in 73% of cases. Primary success was 89.2% (33/37). Four adjunctive procedures were required including two distal extensions (type 1b endoleak and iliac limb disconnection resulting in type III endoleak) and two bypass surgeries (limb graft occlusion and gate cannulation failure). No deaths or major complications were reported during the procedure or in follow-up. No type I, III, or IV endoleak, AAA enlargement, AAA rupture, stent fracture, migration, or endovascular or surgical reintervention were reported during the follow-up period. Type II endoleak was observed in two patients. Asymptomatic narrowing of both iliac limbs was observed in one patient at 6 months. CONCLUSIONS: Our initial experience with the Ovation endograft demonstrated encouraging results in patients with AAA.

Endovascular repair of traumatic thoracic aortic injury: final results from the relay endovascular registry for thoracic disease.

BACKGROUND: In blunt thoracic aortic injury, thoracic endovascular aortic repair (TEVAR) offers a less invasive alternative to open chest surgery. New reliable and accurate stent grafts have widened the endovascular treatment options. We report our experience with the Relay stent graft Bolton Medical, Sunrise, FL; Barcelona, Spain) for treatment of this injury. METHODS: Relay Endovascular Registry for Thoracic Disease (RESTORE) is a multicenter, prospective European registry, which enrolled patients treated with the Relay stent graft for thoracic aortic diseases from April 2005 to January 2009. Regular follow-up examinations were conducted for up to 24 months. This paper analyzes the cohort of patients treated for traumatic aortic injury. RESULTS: Forty adult trauma patients from 12 European centers underwent TEVAR. Mean age was 40 years and 34 patients were male. The proximal landing zone involved aortic arch zones 1 to 2 in 40% and zone 3 in 55% of procedures. Technical success was achieved in all cases. One (2.5%) patient suffered a rupture of the iliac artery. No patient developed procedure-related paraplegia or required conversion to open surgery. Follow-up imaging demonstrated complete exclusion of the traumatic tear and regression of the false aneurysms without endoleak or graft infolding. One late device-related complication was reported; penetration of the distal end of the stent graft treated by stent-graft extension. Thirty-day mortality was 2.5 % (n = 1), and late mortality 2.5% due to a secondary accident. Actuarial 2-year survival was 93.7%. CONCLUSIONS: Thoracic endovascular aortic repair with the Relay stent graft is a safe and effective treatment for patients with traumatic aortic injury.

Hybrid endovascular and surgical approach for mycotic pseudoaneurysms of the extracranial internal carotid artery.

OBJECTIVES: Mycotic pseudoaneurysms of the extracranial internal carotid artery are rare, and their management often represents a challenge, but treatment is necessary due to the high risk of rupture and distal brain embolization. Systemic antibiotics associated with open surgical excision of the infected tissues and carotid reconstruction using autologous grafts are the treatment of choice. The use of endovascular techniques still remains controversial in infective fields; however, it can be an attractive alternative in high-risk patients or more often as a "temporary" solution to achieve immediate bleeding control for a safe surgical reconstruction. METHODS: We discuss the unusual case of an extracranial right internal carotid artery mycotic pseudoaneurysm following methicillin-resistant Staphylococcus aureus infection, in a patient with poor general conditions. RESULTS AND CONCLUSION: The lesion was successfully treated using a hybrid endovascular and surgical procedure.

Straight aortic endograft in abdominal aortic disease.

BACKGROUND: We describe our 8-year experience with the use of endovascular techniques (ET) for the treatment of abdominal aortic aneurysms (AAA) through a straight endograft. METHODS: We retrospectively reviewed data of all patients who were treated for AAA using ET in two centres from 1998 to 2012 and who received a single straight endograft (group A) or a double straight tube (group B). Outcomes were analyzed to assess survival, absence of endoleak and absence of reintervention for both groups. Log-rank and Chi-Square were used as appropriate to make comparison between the two groups. P values < .05 were considered statistically significant. RESULTS: Fifty-three patients from 1998 to May 2012 were treated for AAA using a straight endograft. In 28 cases (52.8%) a single aortic straight tube was used (Group A), while in the remaining cases a "double trombone technique" was used (Group B). CONCLUSIONS: In our experience the endovascular repair of AAA using straight aortic endografts was a safe and effective technique. Reintervention and endoleaks were slightly more frequent in patients who had received a single endograft compared to patients who were treated using the "trombone technique".

Long-term results of carotid artery stenting in patients 80 years and older.

INTRODUCTION: We report our experience about carotid artery stenting (CAS) in patients 80 years and older. MATERIALS AND METHODS: Out of 582 patients who underwent CAS at our institution from January 1999 to June 2010, 102 patients (group A) were 80 years or older. The clinical data of these patients were retrospectively reviewed, outcomes analyzed, and compared with those of younger patients who underwent CAS during the same period (group B). RESULTS: Outcomes of group B were similar to those of group A, both at 30 days and at long term. Male gender, symptoms, and not using an embolic protection device were related to long-term complications in both groups. Occurrence of bradycardia/asystole during CAS was a risk factor for long-term myocardial infarction for group A only. CONCLUSIONS: CAS can be safely performed in patients 80 years or older, with results that compare favorably to those of younger patients.

Delayed endovascular treatment of descending aorta stent graft collapse in a patient treated for post- traumatic aortic rupture: a case report.

BACKGROUND: We report a case of delayed endovascular correction of graft collapse occurred after emergent Thoracic Endovascular Aortic Repair (TEVAR) for traumatic aortic isthmus rupture. CASE PRESENTATION: In 7th post-operative day after emergent TEVAR for traumatic aortic isthmus rupture (Gore TAG® 28-150), a partial collapse of the endoprosthesis at the descending tract occurred, with no signs of visceral ischemia. Considering patient's clinical conditions, the graft collapse wasn't treated at that time. When general conditions allowed reintervention, the patient refused any new treatment, so he was discharged.Four months later the patient complained of severe gluteal and sural claudication, erectile disfunction and abdominal angina; endovascular correction was performed. At 18 months the graft was still patent. DISCUSSION AND CONCLUSION: Graft collapse after TEVAR is a rare event, which should be detected and treated as soon as possible. Delayed correction of this complication can be lethal due to the risk of visceral ischemia and limbs loss.

Endovascular treatment of iatrogenic axillary artery pseudoaneurysm under echographic control: a case report.

AIM: Brief case report of the treatment of a large axillary artery pseudoaneurysm after a pacemaker using a left brachial cutdown and a retrograde delivery of a covered stent using ultrasound and fluoroscopic guidance. The patient's renal function precluded the use of contrast materials. CASE REPORT: A 77 years old man presenting with acute renal failure and haemoglobin decrease arrived with an expanding pseudoaneurysm of the left axillary artery from a pacemaker placement. Considering the site of the lesion and patient's comorbidities, under echographic control, a Hemobahn® stent-graft was placed; fluoroscopy assisted manipulation of guidewires and sheaths into the aortic arch. The procedure was successfully ended without any complications. At 8 months the stent graft was still patent. CONCLUSION: Ultrasound guidance may represent an alternative for pseudo-aneurysm exclusion without any use of contrast medium, especially in those patient where lesions are easily detectable using ultrasonography and when comorbidities contraindicate aggressive surgical or angiographic approach.

Endovascular treatment of patients with types A and B thoracic aortic dissection using Relay thoracic stent-grafts: results from the RESTORE Patient Registry.

PURPOSE: To evaluate the safety and performance of Relay stent-grafts in patients with acute or chronic aortic dissections. METHODS: Patients with types A or B aortic dissections suitable for treatment with Relay stent-grafts and followed for 2 years after thoracic endovascular aortic repair (TEVAR) were identified from a company-sponsored registry database established in January 2006. Ninety-one consecutive patients (69 men; mean age 65 years) underwent TEVAR with Relay stent-grafts for dissection. Most patients (76, 84%) had type B dissections; 61 of all patients were classified as chronic and 30 as acute. RESULTS: The technical success rate was 95% (97% in acute, 95% in chronic, and 93% in type B dissections). The type I endoleak rate was 7% (7% in acute and 8% in chronic dissections); all occurred in patients with type B dissections. Paraplegia, paraparesis, and stroke occurred in 4, 1, and 2 patients, respectively; 2 cases of paraplegia occurred in patients with acute type B dissections. Thirty-day mortality was 8% (13% in acute and 5% in chronic dissections); all deaths occurred in patients with type B dissections. The 2-year survival rate was 82% in the overall population and 84% in patients with type B dissections. CONCLUSION: The combination of Relay's features, such as stent conformability, radial force, atraumatic design, and controlled deployment and fixation, may contribute to the safety of the Relay stent-grafts for the treatment of thoracic aortic dissections, including acute and chronic type B dissections.

Evaluation of inflammatory status of atherosclerotic carotid plaque before thromboendarterectomy using delayed contrast-enhanced subtracted images after magnetic resonance angiography.

OBJECTIVE: To investigate the correlation among carotid plaque contrast enhancement (CPCE) at MRI, inflammatory cell infiltration (ICI) at histopathology, and carotid stenosis degree. MATERIALS AND METHODS: Twenty-eight patients (19 males; mean age 67±9 years) scheduled for thromboendarterectomy prospectively underwent 1.5-T MR imaging using: (a) axial T1-weighted gradient-echo (T1wGRE) sequence centered on carotid bifurcations; (b) contrast-enhanced MR angiography (CE-MRA) with 0.1 mmol/kg of gadobenate dimeglumine; (c) enhanced axial T1wGRE sequence as in (a), 3 min after contrast injection. A three-point score system (absent, focal, wide) was used to assess CPCE on native and subtracted MRI images (c minus a) and ICI at histopathology. Carotid stenosis degree was determined on CE-MRA. RESULTS: Six CPCE studies were discarded due to patient movement. In the remaining 22 studies, CPCE was absent, focal and wide in 13, 6 and 3 cases, respectively; ICI was absent, focal and wide in 13, 7 and 2 cases, respectively (k=0.57). On CE-MRA 21/28 stenoses were severe and 7/28 moderate. There was no correlation either with ICI (p=1.000, n=28) or CPCE (p=0.747, n=22). CONCLUSION: The correlation between CPCE and ICI suggests a role for CPCE as an independent marker of plaque inflammation.

Final operative and midterm results of the European experience in the RELAY Endovascular Registry for Thoracic Disease (RESTORE) study.

PURPOSE: Thoracic endovascular aortic repair is increasingly becoming the standard treatment of many thoracic aortic pathologies. New reliable and accurate stent grafts are emerging to widen the endovascular treatment options. We report the results of RELAY (Bolton Medical, Barcelona, Spain) in the large RELAY Endovascular Registry for Thoracic Disease (RESTORE) European registry. METHODS: RESTORE is a multicenter, prospective European registry involving 22 centers in seven European countries. The RELAY device is composed of a stent graft (self-expanding nitinol stents and a polyester vascular graft) and a delivery device specifically designed for the thoracic aorta. Included were acute and elective patients presenting with a variety of pathologies (aneurysms, dissections, ulcerations, intramural hematomas, pseudoaneurysms) and lesions in different aortic and anatomic locations (ascending, arch, descending and thoracoabdominal). RESULTS: The registry enrolled 304 patients from April 2005 to January 2009. All-cause mortality at 30 days was 7.2%. Freedom from all cause mortality and freedom from device- and procedure-related mortality at 2 years were 78.5% and 95.9%, respectively. An average of 1.26 graft components were used per patient, with a technical success of 97.7% irrespective of the etiology. Early endoleak rate was 4.6%. Perioperatively, stroke and paraplegia were registered in 1.6% and 2.0%, respectively. CONCLUSIONS: The results of RESTORE support the safety of thoracic endovascular aortic repair with the RELAY stent graft, even in acute and complicated situations. The device was highly efficient in angulated aortic anatomies, with acceptable mortality and a low rate of neurologic complications.

Uninfected para-anastomotic aneurysms after infrarenal aortic grafting.

PURPOSE: This single-institution retrospective review examines the management of uninfected para-anastomotic aneurysms of the abdominal aorta (PAAA), developed after infrarenal grafting. MATERIALS AND METHODS: From October 1979 to November 2005, 31 PAAA were observed in our Department. Twenty-six uninfected PAAA of degenerative etiology, including 24 false and 2 true aneurysms, were candidates for intervention and retrospectively included in our database for management and outcome evaluation. Six (23%) patients were treated as emergencies. Surgery included tube graft interposition (n = 12), new reconstruction (n = 8), and graft removal with extra-anatomic bypass (n = 3). Endovascular management (n = 3) consisted of free-flow tube endografts. RESULTS: The mortality rate among the elective and emergency cases was 5% and 66.6%, respectively (p = 0.005). The morbidity rate in elective cases was 57.8%, whereas 75% in emergency cases (p = 0.99). The survival rate during the follow-up was significantly higher for elective cases than for emergency cases. CONCLUSION: Uninfected PAAA is a late complication of aortic grafting, tends to evolve silently and is difficult to diagnose. The prevalence is underestimated and increases with time since surgery. The mortality rate is higher among patients treated as an emergency than among patients who undergo elective surgery, therefore, elective treatment and aggressive management in the case of pseudoaneurysm are the keys to obtain a good outcome. Endovascular treatment could reduce mortality. Patients who undergo infrarenal aortic grafting require life-long surveillance after surgery.

Endovascular treatment of ruptured iliac aneurysm previously treated by endovascular means.

A patient with a ruptured iliac aneurysm was admitted to the Emergency Department in hypovolemic shock. He had previously undergone surgical treatment for an infrarenal abdominal aortic aneurysm, which was managed with a terminal-terminal Dacron tube graft. Subsequently, he developed two iliac aneurysms, which were treated endovascularly with two wall-grafts in the right and one wall-graft in the left iliac arteries. He suffered chronic renal failure and arterial hypertension. Contrast-enhanced computed tomography showed rupture of the right iliac aneurysm and dislocation of the two wall-grafts. He was treated in an emergency situation with the implantation of an iliac endograft that bridged the two wall-grafts, which resulted in hemostasis and stabilization of his condition. Five days later, in an elective surgical situation, he was treated with the implantation of an aorto-uni-iliac endograft combined with a femoral-femoral bypass. He was discharged 5 days later in good condition. At the 4 year follow-up visit, the endoprosthesis remained in place with no evidence of an endoleak. In conclusion, overlapping of endografts should be avoided, if possible. Strict surveillance of the endovascularly treated patient remains mandatory.

[Endovascular repair of aortic abdominal aneurysms in octagenarian patients: early and midterm results]. / Trattamento endovascolare di Aneurismi dell'aorta addominale in pazienti ottantenari. Risultati a medio termine.

AIM OF THE STUDY: This article summarizes our experience in endovascular repair of abdominal aortic aneurysm in octogenarian patients. MATERIAL AND METHODS: From January 2000 to December 2005 30 patients (mean age 84 years) underwent endovascular repair of abdominal aortic aneurysm; in 28 cases a loco-regional anaesthesia has been performed. Twenty-eight bifurcated graft, one straight graft and one aorto-iliac graft have been used. RESULTS: No operative mortality or early endoleak have been observed; during the follow-up period (20 months) 7 endo-leaks (3 cases type I; 4 cases type II) have been reported; all patients with type I EL underwent endovascular repair; in two patients with type II EL we observed spontaneous regression; the other cases are still monitored in absence of sac enlargement. Four graft occlusions have been observed; one early thrombosis has been treated with surgical thrombectomy, two of the three late occlusions required other procedures. Five patients died during the follow-up period, three of them during the first year. No death has been aneurysm related. DISCUSSION: In accord with other recent studies, our analysis confirms the positive impact on intra-operative and early post-procedural mortality of the endovascular therapy for abdominal aortic aneurysm in octogenarian patients; no evidence of significative benefit on late survival has been observed. CONCLUSION: In conclusion we consider endovascular option as the best approach in octogenarian patients even if a longer follow-up is mandatory.

Late gastrointestinal bleeding after infrarenal aortic grafting: a 16-year experience.

PURPOSE: To review the manifestation and management of gastrointestinal (GI) bleeding caused by secondary aortoenteric fistula (AEF) after infrarenal aortic grafting. METHODS: Between 1991 and 2006, nine patients underwent emergency treatment for secondary AEF localized in the duodenum (78%), ileum (11%), or sigmoid colon (11%). Three (33%) patients suffered hypovolemic shock. There were two (22%) real fistulas and seven (78%) paraprosthetic fistulas. Graft infection was confirmed in four (45%) patients and four (45%) had proximal sterile pseudoaneurysms. Surgical management consisted of graft removal with (n = 5) or without simultaneous extra-anatomic bypass (n = 1), in situ Dacron graft interposition (n = 3), ileo-duodenorrhaphy (n = 8), sigmoidectomy with colostomy (n = 1), and segmentary ileectomy (n = 1). Endografting was used only as a temporary measure to control bleeding in two patients. RESULTS: The mortality rate was 55% (n = 5). There were no intraoperative deaths, but 75% of the septic patients, 66% of those with preoperative hemodynamic instability, 50% of those with pseudoaneurysms, and 100% of those who required bowel resection died during the early postoperative period. Moreover, all of the surviving patients suffered early postoperative morbidity, resulting in prolonged intensive care unit stay and hospitalization. CONCLUSIONS: Secondary AEF is life-threatening, difficult to treat, and associated with high morbidity and mortality, especially in patients with sepsis or hemodynamic instability and those requiring bowel resection.

Aortic neck dilatation and endograft migration are correlated with self-expanding endografts.

PURPOSE: To compare self-expanding and balloon-expandable stent-grafts in terms of aortic neck dilatation and endograft migration. METHOD: Two-hundred and forty-two patients (178 men; mean age 68 years, range 56-91) underwent elective endovascular repair of abdominal aortic aneurysm. Two-hundred self-expanding (115 Excluder, 48 Endologix, 23 Vanguard, 10 Anaconda, and 4 Talent) and 42 balloon-expandable (Lifepath) endografts were used. All patients underwent contrast-enhanced computed tomography (CT) prior to the intervention, at 1, 3, and 6 months after the procedure, and annually thereafter. Comparison was made between the first and the last follow-up CT scans. RESULTS: Fifty-five (27.5%) of the 200 patients treated with self-expanding endografts had aortic neck dilatation compared to only 3 (7.1%) of the 42 patients treated with balloon-expandable endografts (p = 0.023). Forty-nine (24.5%) patients in the self-expanding group versus only 3 (7.1%) patients of the balloon-expandable group presented with endograft migration (p = 0.034); all had dilated necks. The difference between the means of neck dilatation for the Lifepath balloon-expandable stent-graft and the Excluder self-expanding endoprosthesis was statistically significant (p = 0.011, 95% CI 0.07 to 0.91). CONCLUSION: Aortic neck dilatation following endovascular AAA repair appears to be correlated with self-expanding endografts, which may contribute to a higher incidence of graft migration compared to that occurring with balloon-expandable endografts.

[The surgical and endovascular treatment of the hepatic artery aneurysms: personal experience]. / Il trattamento chirurgico ed endovascolare degll' aneurismi dell'arteria epatica. Esperienza personale.

OBJECTIVE: The aim of this single-institution retrospective study is to report the results of surgical and endovascular treatment of hepatic artery aneurysms. MATERIALS AND METHODS: Twenty patients with an extraparenchimal hepatic artery aneurysm made part of the study In the first period, between February 1980 and December 1996, 12 patients were admitted and treated surgically. In the second period, January 1997 until December 2005, 8 patients were admitted. Four were treated surgically and 4 with an endovascular procedure. The aneurysms ranged from 2.3 cm to 6.2 cm Seventeen patients were asymptomatic, while three were symptomatic for pain and obstructive icterus. In 13 patients aneurysmectomy and graft interposition was performed, in three patients aneurysmectomy with dacron patch interposition was performed, and in 4 patients the aneurysm was excluded with a stent-graft. RESULTS: No perioperative mortality was noted and no major complication occurred. All endovascular procedures successfully excluded the aneurysm without signs of endoleak. Follow-up in 4 months, 6 months and 10 months postoperatively showed patency of the stent-graft with no signs of migration or endoleak. Only in one case, in the 8th post-operative month, thrombosis of the stent-graft occurred and the patient was completely asymptomatic. CONCLUSION: The natural history of hepatic artery aneurysms is rupture, and consequently there is an indication of treatment. Actually, we consider endovascular treatment as the first-choice-treatment whenever possible. Endovascularlly treated patients need a strict follow-up surveillance by imaging means. Particular attention so be given in the preoperative study of the collateral circulation in patient treated surgically.

Carotid endarterectomy in patients with contralateral carotid artery occlusion.

The aim of this study was to evaluate the 30-day outcome of carotid endarterectomy in patients with contralateral carotid artery occlusion and compare it to that in patients with patent contralateral carotid artery. We compared 2,959 carotid endarterectomies performed in patients with patent contralateral internal carotid artery to 373 carotid endarterectomies performed in patients with occlusion of the contralateral carotid artery in the same institute between 1988 and 2004. Patient demographics, surgical and anesthesiological strategy, perioperative neurological and cardiac events, and deaths were compared. The patients were grouped and analyzed according to the presence or absence of symptoms and to their gender. No significant difference was shown in perioperative cardiological and neurological events and deaths in patients with contralateral carotid occlusion versus patients without contralateral carotid occlusion. Females had significant more neurological events than males, in both the asymptomatic (P < 0.001) and symptomatic (P = 0.02) groups. Concomitant occlusion of the contralateral carotid artery was not associated with increased risk of perioperative cardiological or neurological adverse events. However, female gender was associated with higher risk for adverse neurological events.

Stent explantation from an arteriovenous fistula for hemodialysis: a case report.

Percutaneous transluminal angioplasty is the first treatment of a dysfunctional vascular access for hemodialysis. A case of stenting of a native arteriovenous hemodialysis fistula is reported that was treated with a stent placement at the anastomosis level, with explantation of the stent after complete thrombosis of the fistula 48 hours after the procedure. It is preferable to treat arteriovenous fistulas with simple balloon dilatation, avoiding stenting of the fistula, especially in the anastomosis site.