Dual- vs single-layer stents for endovascular treatment of symptomatic and asymptomatic internal carotid artery stenosis.

BACKGROUNDS: Plaque protrusion is a common event among carotid artery stenting (CAS) patients and increases ischemic complication risk. Dual-layer stents (DLS) with micromesh technology may offer greater plaque protection compared to single-layer stents (SLS), but few data are available. The aim of the study is to compare clinical outcomes at 12 months for asymptomatic and symptomatic patients treated for primary CAS with DLS or SLS in a high-volume center. METHODS: A retrospective analysis of consecutive symptomatic and asymptomatic patients treated with primary CAS for internal carotid artery (ICA) stenosis, with either DLS or SLS between 2015 and 2019, was performed. Primary endpoints included rates of ipsilateral transient ischemic attacks (TIA)/stroke and death within 1-year from CAS. Secondary endpoints included patency rates and survival according to stent type. RESULTS: Of the 301 patients who met inclusion criteria (74.8 % male; 73.6 mean age ± 8.7 years), most patients were asymptomatic (77.4 %). Among all patients DLS was most frequently deployed (66 %); also, among asymptomatic (62 %) and symptomatic patients (81 %), p < 0.01. Symptomatic patients had less comorbidities and severe disease than asymptomatic patients. Six peri-operative strokes were recorded and, within 1 year, 2 additional strokes were registered among symptomatic patients treated with SLS. No post-operative strokes were encountered in the DLS group (p = 0.04) among symptomatic patients. Higher rates of TIA were observed among asymptomatic patients treated with DLS compared to SLS while rates of TIA were reduced among symptomatic patients treated with DLS. There were no differences in patency rates for DLS and SLS in symptomatic and asymptomatic patients. Primary patency was similar among DLS stent types but differed among SLS stent types (p = 0.01). At a mean follow-up of 27 months ±17.6, survival was comparable between DLS and SLS groups (p = 0.98). CONCLUSION: CAS with DLS seems to reduce the risk of post-procedural stroke for symptomatic patients compared to SLS whilst the choice of stent did not influence ipsilateral TIA, survival or patency rates. These data require confirmation from larger, randomized, prospective studies.

Carotid endarterectomy in asymptomatic octogenarians: Outcomes at 30 days and 5 years.

BACKGROUND: The following study investigated the 30-day and 5-year relative survival rate and freedom from neurological events in asymptomatic carotid stenosis (ACS) octogenarians who had undergone elective carotid endarterectomy (CEA). METHODS: Between January 2008 and June 2014, a retrospective review was conducted on ACS patients who had undergone elective CEA. The patients' sample was divided into two groups: Group A (GA) included octogenarians and Group B (GB) included younger patients. The GA patients were subjected to a risk-scoring system and follow-up. The two groups were compared analysing the following primary endpoints: 30-day mortality, stroke, stroke/death and acute myocardial infarction (AMI); GA patients' survival rate and freedom from neurological events at 5 years. The 30-day secondary endpoints included carotid shunting, redo surgical, need for general anaesthesia with preserved consciousness (GAPC) conversion and length of hospital stay. RESULTS: We identified 620 patients with ACS, of them 144 (23.2%) belonged to the GA and 476 (76.8%) belonged to the GB. No statistical difference between the two groups was found regarding the primary and secondary endpoints. One hundred nineteen of 144 GA patients (82.6%) underwent the follow-up; the median follow-up was 78.3 months. The GA patients' 5-year survival rate was 62%, while freedom from cerebral events was 94.9%. Analysis regarding GA patients' 5-year survival rate revealed a significantly lower percentage among the patients with a severe risk score compared with those with a moderate risk score (respectively, 29.5% vs 67.7%; p = .005). The multivariate analysis showed that chronic obstructive pulmonary disease (COPD) and chronic kidney disease (CKD) were independently associated with lower survival. CONCLUSIONS: The 30-day outcomes of CEA in octogenarians are comparable to those in younger patients. Comprehensive life expectancy and preoperative score, rather than age alone, should be taken into account before performing CEA on octogenarian patients, considering the short- and long-term efficacy in stroke prevention.

Surgical and Endovascular Management of Isolated Internal Iliac Artery Aneurysms: A Systematic Review and Meta-Analysis.

OBJECTIVES: The purpose of this paper is to report the different modalities for the treatment of isolated internal iliac artery aneurysms (IIIAA), as well as their outcomes. METHODS: We performed a systematic review of the literature (database searched: PubMed, Web of Science, Scopus, Cochrane Library; last search: April 2020). We included articles reporting on the outcomes for IIIAA interventions comprising at least 5 patients. Studies were included when presenting extractable outcome data regarding intraoperative and/or early results. We performed meta-analyses of proportions for different outcomes, using random effects model. RESULTS: Thirteen non-randomized studies were included (192 patients with 202 IIIAA). IIIAA were symptomatic in the 18.1% (95%CI 9.3-26.9; I2 54.46%, P = .019). Estimated mean IIIAA diameter was 46.28 mm (95%CI 39.72-52.85; I2 88.85%, P < .001). Open repair was performed in 21/202 cases. Endovascular treatments were: embolization (81/181), embolization and hypogastric artery coverage (79/181), hypogastric artery coverage by stent-grafting (15/181), stent-grafting in the hypogastric artery (6/181). Overall estimated technical success (TS) rate was 91.6% (95% CI 86.8-95.5; I2 45.82%, P = .031). TS rate was 94.5% for open surgery (95%CI 85.3-100; I2 0%, P = .907), and 89.7% for endovascular repair (95%CI 83.8-95.6; I2 55.43%, P = .006). Estimated overall 30-day mortality was 3.1% (95%CI 0.8-5.4; I2 0%, P = .969). Mortality rates after open surgery and endovascular repair were 8.2% (95%CI 3.4-19.8; I2 0%, P = .545) and 2.8% (95%CI 0.5-5.1; I2 0%, P = .994), respectively. Estimated mean follow-up was 32.63 months (95%CI 21.74-43.53; I2 94.45%, P < .001). During this timeframe, IIIAA exclusion was preserved in 92.8% of the patients (95%CI 89.3-96.2; I2 0%, P = .797). Buttock claudication occurred in 13.9% of the patients (95%CI 8.7-19.2; I2 0%, P = .622). CONCLUSIONS: IIIAA are frequently large, and symptomatic at presentation. Several treatments are proposed in literature, open and endovascular, both with good results. The endovascular treatment is the preferred method of treatment in literature, since it offers good short- to mid-term results and low early mortality. Buttock claudication after hypogastric artery exclusion is a common complication.

Complete Relining in Type 3 Endoleak with AFX Endograft Billowing and Severe Kinking: A Case Report.

BACKGROUND: Type 3 endoleak (T3E) is usually treated by endovascular relining. The procedure can be technically complex in cases of endografts with kinking of innermost stents. We report a case of T3E in an AFX (Endologix, Irvine, CA, USA) endograft with sac enlargement, billowing, and severe kinking of the main body stents, managed with a complete relining endovascular procedure. METHODS: A 69-year-old man with severe comorbidities and prior aorto-bi-iliac AFX endograft completed by an Endurant II cuff (Medtronic, Santa Rosa, CA, USA) for a 63-mm asymptomatic infrarenal aneurysm was admitted to our department for a T3E with 7-mm sac enlargement. The computed tomography angiography (CTA) showed perfusion of the aneurysmal sac, AFX fabric disconnection from its stent (billowing), and severe stent kinking of the main body without a residual lumen. A digital subtraction angiography confirmed the T3E. A complete relining was performed by deploying a bifurcated Endurant II through the AFX stents. RESULTS: The 1-year CTA proved the resolution of the endoleak with a stable aneurysmal sac diameter. CONCLUSIONS: In case of T3E with severe main body stent kinking and graft billowing, an endovascular procedure with a complete aorto-bi-iliac relining through inner stents may be considered.

Results of the endovascular abdominal aortic aneurysm repair using the Anaconda aortic endograft.

OBJECTIVE: The objective of this study was to evaluate early and late results of the Anaconda aortic endograft (Vascutek, Terumo, Inchinnan, Scotland) in a single-center experience. METHODS: From September 2005 to March 2012, patients underwent endovascular aortic repair for abdominal aortic aneurysm (AAA) with Anaconda endograft were prospectively enrolled in a dedicated database. Demographic and aortoiliac morphological data were considered. Preoperative planning was based on thoracoabdominal and pelvic computed tomography angiography. Follow-up included duplex ultrasound or computed tomography angiography at 1, 6, and 12 months and yearly thereafter. Primary end points were technical success, early and late primary and primary assisted clinical success (CS), overall and AAA-related survival and freedom from reinterventions. Secondary end points were endoleaks (ELs), steno-obstructive iliac leg complications, and AAA shrinkage. RESULTS: An Anaconda endograft was implanted in 177 patients (male 94%; mean age, 73.3 ± 7.4 years; American Society of Anesthesiologists class III-IV, 85% and 9%, respectively). The mean AAA diameter, neck length, and diameter were 55 ± 9.7 mm, 26.7 ± 10 mm, and 23 ± 2.3 mm, respectively. There was an aortic neck angle >60° in 44 (25%) patients. Iliac angles >90° were observed in 152 (43%) iliac axes. Technical success was 98.9%. Early CS was 96%. Mean follow-up was 33 ± 23.3 months. Late assisted CS was 97.7%. Survival at 12, 24, and 36 months was 96.4%, 89%, and 86.2%, respectively. There was only one case of late AAA-related mortality. Freedom from reintervention was 94%, 92%, and 85% at 12, 24, and 36 months, respectively. Three (1.7%) conversions occurred during follow-up. There were 14.1% ELs at the completion angiography (EL Ia, 1.1%; EL II, 13%). Late ELs were 20.2% (EL Ia, 1.1%; EL Ib, 2.2%; EL II, 16.9%). Iliac leg complications occurred in 5.6% of the cases. An AAA shrinkage >5 mm was observed in 130 (73.4%) patients. In 7 (4%) cases there was an AAA enlargement >5 mm. CONCLUSIONS: Data in our series demonstrate that the Anaconda endograft has good early and late results in the treatment of AAAs.