Preliminary experience with new generation balloon expandable stent-graft in the treatment of innominate artery obstructive disease.

BACKGROUND: The aim of this study was to describe a single center preliminary experience with the use of a specific balloon expandable stent-graft for the treatment of innominate artery (IA) obstructive lesions. METHODS: We report our experience with four male patients treated with Gore Viabahn balloon (Gore Medical, Flagstaff, AZ, USA) expandable stent-graft for different types of IA stenosis: three patients were symptomatic for vertebrobasilar insufficiency, while one patient was asymptomatic for cerebrovascular symptoms. The stent grafts were deployed using retrograde (N.=2) or antegrade approach (N.=2), aiming to cover the entire lesions length and to slightly protrude into the aortic arch. Post-dilatation was performed with a compliant balloon. One patient presented a tandem lesion (IA and right internal carotid artery) and after the stenting of the IA he was treated also with a carotid artery stenting during the same procedure. RESULTS: Technical success was achieved in all patients. No perioperative or postoperative complications had been reported and the neurological disorders disappeared for the three symptomatic patients. After a mean clinical and radiological follow-up of 24±5 months, all the stents were patent and perfectly adapted to the vessels. CONCLUSIONS: This preliminary clinical experience shows that the use of the Gore Viabahn balloon (Gore Medical) expandable stent-graft seems safe and feasible for the treatment of the IA obstructive lesions, also in presence of irregular plaques and hostile anatomies for an endovascular treatment. Larger experiences and long-term data are mandatory.

Multiple Parallel Grafts for Urgent Endovascular Repair of a Ruptured Mycotic Aortic Aneurysm.

A 73-year-old woman underwent urgent endovascular repair of a ruptured mycotic aortic aneurysm. A thoracic stent graft was employed as the main endograft, while the celiac trunk and superior mesenteric artery were revascularized by the chimney technique and the renal arteries through the periscope technique. Postoperative computed tomography revealed a Type A1 gutter, treated by detachable coils and peripheral occlusion devices. Six-month follow-up revealed patency of the stent grafts, without endoleak or stent graft infection signs.

The Chimney/Periscope Technique as Total Endovascular Treatment of Kommerell's Diverticulum.

We report a case of Kommerell's diverticulum (KD) treated with a total endovascular approach, maintaining supra-aortic trunk (SAT) patency. A 75 year-old female with aneurysmal KD was deemed unsuitable for open surgery. Landing zone 2 was unfeasible; therefore, we planned an endovascular approach with landing in zone 1, chimney to left subclavian artery and periscope to right subclavian artery. Postoperatively she was free from complications, with complete exclusion of KD and SAT patency at 3-year follow-up.

Development and validation of an improved classification and risk stratification system for carotid body tumors: Multinational collaborative cohort study.

BACKGROUND: This study aims to develop and validate a new classification system that better predicts combined risk of neurological and neurovascular complications following CBT surgery, crucial for treatment decision-making. METHODS: Multinational retrospective cohort study with 199 consecutive cases. A cohort of 132 CBT cases was used to develop the new classification. To undertake external validation, assessment was made between the actual complication rate and predicted risk by the model on an independent cohort (n = 67). RESULTS: Univariate analyses showed statistically significant associations between developing a complication and the following factors: craniocaudal dimension, volume, Shamblin classification, and Mehanna types. In the multivariate prognostic model, only Mehanna type remained as a significant risk predictor. The risk of developing complications increases with increasing Mehanna type. CONCLUSIONS: We have developed and then validated a new classification and risk stratification system for CBTs, which demonstrated better prognostic power for the risk of developing neurovascular complications after surgery.

Early outcomes of routine delayed shunting in carotid endarterectomy for symptomatic patients.

BACKGROUND: The role of shunting during carotid endarterectomy (CEA) in symptomatic patients is unclear. The aim was to evaluate early outcomes of CEA with routine "delayed" shunt insertion, for patients with symptomatic carotid stenosis. METHODS: We conducted a single-center retrospective study of symptomatic patients undergoing CEA (2009-2020). All CEAs were performed under general anesthesia using a standardized technique, based on delayed routine shunt insertion after plaque removal. Primary endpoints were 30-days mortality and stroke. A logistic regression was performed to identify clinical and procedural factors associated with postoperative stroke. RESULTS: Two-hundred-sixty-three CEAs were performed for TIA (N.=178, 47%) or acute ischemic stroke (N.=85, 32%). Mean delay of surgery was 6±19 days, and early CEA (<48 hours) was performed in 98 cases (37%). Conventional CEA was performed in 171 patients (67%), eversion CEA in 83 (33%). Early (30-days) mortality was 0.3%. Stroke/death rate was 2.3%. Female sex (OR=5.14, 95% CI: 1.32-24.93; P=0.023), use of anticoagulants (OR=10.57, 95% CI: 2.67-51.86; P=0.001), preoperative stroke (OR=5.34, 95% CI: 1.62-69.21; P=0.006), and the presence of preoperative CT/MRI cerebral ischemic lesions (OR=5.96, 95% CI: 1.52-28.59; P=0.013) were associated with early neurological complications. Statin medication (OR=0.18, 95% CI: 0.04-0.71; P=0.019) and CEA timing <2 days (OR=0.14, 95% CI: 0.03-0.55; P=0.005) were protective from postoperative stroke. CEA outcomes were independent from time period (P=0.201) and operator's volume (P=0.768). A literature systematic review identified other four studies describing the CEA outcomes with routine shunting in symptomatic patients, with a large variability in the selection of patients, surgical technique, and description of the results. CONCLUSIONS: Routine delayed shunting after plaque removal seems to be a safe and effective technique, that contributed to maintain a low complication rate in neurologically symptomatic patients. Statin use and expedited timing were associated with improved outcomes using this technique.

Early and midterm outcomes of endovascular aneurysm repair with an ultra-low-profile endograft from the Triveneto Incraft Registry.

OBJECTIVE: We evaluated the early and midterm outcomes of the Incraft (Cordis Corp, Bridgewater, NJ) ultra-low-profile endograft by analyzing data from the Triveneto Incraft Registry (TIR). METHODS: TIR is an independent multicenter cohort registry of 10 vascular surgery units in the Triveneto area (Northeast Italy). A prospective analysis of patients electively treated with Incraft from September 2014 to June 2019 was performed. The main outcomes were technical success, major 30-day complications, 30-day aneurysm-related death, freedom from reintervention, and mortality rate during follow-up and were analyzed using Kaplan-Meier curves. Univariable Cox regression was used to evaluate the associations between anatomic complexity factors and reintervention. RESULTS: During the study period, 209 patients were included in the registry. Their mean age was 76.9 ± 7.7 years and the Society for Vascular Surgery comorbidity score was 0.97 ± 0.52. Most patients (n = 181; 86.6%) had presented with at least one complex anatomic factor: aortic neck angle α <135° in 31 patients (14.8%), conic neck in 17 patients (8.2%), iliac tortuosity index τ >1.5 in 102 (48.8%), iliac artery calcification >50% in 106 (50.7%), and external iliac artery <6 mm in 45 (21.5%). The concurrent presence of two or more complex iliac anatomic factors was present in 67 patients (32.1%). The technical success rate was 99.5%, and the early major complication rate was 1.5% (one limb occlusion, one iliac branch stenosis, one type III endoleak [EL]). No 30-day mortality was recorded. The mean follow-up period was 18.5 ± 13.2 months. The overall mortality was 9.5% (n = 18), none related to the aneurysm. The freedom from reintervention rate was 92.1%. Of these patients, six (3.2%) had been treated for type II EL embolization, one (0.5%) for type IA EL, four (2.1%) for iliac branch occlusion, and one (0.5%) for flow-limiting external iliac artery dissection. None of the single anatomic factors analyzed were predictive of reintervention. However, the association of two or more complex iliac anatomic factors was predictive of related reintervention (hazard ratio, 7.25; P = .014). The crude reintervention rate in this complex subgroup of patients was low (4 of 67; 6%). CONCLUSIONS: Data from the TIR have demonstrated excellent early and midterm outcomes of endovascular aneurysm repair using the Incraft stent graft in patients with complex anatomy. The concurrent presence of two or more complex iliac anatomic factors still represent an issue for endovascular aneurysm repair success. However, the technical characteristics of this device resulted in low intervention rates, even for patients with these challenging issues.

Transapical Deployment of Thoracic Stent Graft for Ascending Aorta Coronary Bypass Pseudoaneurysm in a Patient with Prosthetic Aortic Valve.

The authors describe the transapical deployment of a thoracic endograft to exclude a saphenous vein graft proximal anastomotic pseudoaneurysm following coronary artery bypass grafting (CABG) in a 63-year-old male with a prosthetic aortic valve. A standard thoracic endograft has been deployed via transapical access after percutaneous transluminal coronary angioplasty of the native vessel perfused by the patent CABG. The procedure was uneventful; an 8-month computed tomography scan showed complete exclusion of the pseudoaneurysm with patency of supra-aortic trunks.

Early Outcomes of Routine Delayed Shunting in Carotid Endarterectomy for Asymptomatic Patients.

OBJECTIVE/BACKGROUND: The aim was to evaluate early outcomes of carotid endarterectomy (CEA) in asymptomatic patients using a standardised technique based on routine shunting after rapid plaque removal ("delayed"). METHODS: A retrospective review of all asymptomatic patients who underwent CEA during a 10 year single centre experience (January 2007-December 2016) was performed. The technique was based on rapid endarterectomy with distal intimal edge visualisation, followed by routine shunt insertion; subsequent time spent on the manoeuvre and closure were completed under shunting. Primary endpoints were relevant neurological complication rate (RNCR) and death within 30 days. To better identify any difference related to changes in medical therapy, anaesthetic management, and different operators over time, patients were divided into group A (underwent CEA in the first 5 year period) and group B (underwent CEA during the second 5 year period). Univariate analysis of factors associated with RNCR was performed. Operator experience (seniority), expertise (CEA volume per year), and time period were incorporated. RESULTS: In total, 1745 patients matched the inclusion criteria and were enrolled. Altogether, 147 (8.9%) had contemporary contralateral stenosis ≥70% and 58 (3.5%) had contralateral internal carotid artery chronic occlusion. No patient died peri-operatively; major myocardial infarction occurred in 19 patients (1.1%). Overall, peri-operative RNCR was 0.6% (major stroke: n = 6 [0.4%]; minor stroke: n = 4 [0.2%]). RNCR distribution was maintained equally comparing group A and B (0.8% vs. 0.4%; p = 0.17). No differences were found in RNCR when comparing operator experience (p = 0.88) and expertise (p = 0.93). Univariable analysis found diabetes as the only clinical factor influencing RNCR (odds ratio 3.79, 95% confidence interval 1.06-13.50; p = 0.04); none of the other factors, such as time period, operator experience, and expertise, reached statistical significance. CONCLUSIONS: Routine delayed shunting associated with standardisation of the technique seems to be a safe and effective technique and contributes to maintaining the RNCR < 1% over time and independently from operators and other clinical factors.

A national Vascular Quality Initiative database comparison of hybrid and open repair for aortoiliac-femoral occlusive disease.

OBJECTIVE: We sought to analyze the outcomes of revascularization for aortoiliac-femoral occlusive disease by comparing hybrid repair by endovascular revascularization and open common femoral endarterectomy (ER-CFE) with open aortoiliac reconstruction and CFE (OR-CFE). METHODS: Using the national Society for Vascular Surgery Vascular Quality Initiative database from 2009 to 2015, we identified all patients receiving open or endovascular revascularization of the aortoiliac system and who additionally underwent CFE. Patients with concomitant infrainguinal procedures were excluded, as were procedures performed at centers with <50% 9-month or longer follow-up. Main outcome variables were 30-day mortality, length of stay, 1-year mortality and patency, ankle-brachial index (ABI), secondary interventions, major amputations, and ambulatory status. RESULTS: After exclusions, the cohort comprised 879 patients in the OR-CFE group and 1472 in the ER-CFE group with follow-up of at least 9 months. Patients with ER-CFE were older (68 ± 9 years vs 63 ± 9 years; P < .001) and were more likely to have diabetes (37% vs 29%; P < .001) or heart failure (13% vs 9%; P < .01). Those receiving OR-CFE were more likely to have received a previous inflow procedure (27% vs 21%; P < .001). A greater number of arterial segments were treated or bypassed for patients undergoing OR-CFE (5.2 ± 1.6 vs 2.9 ± 1.0; P < .01). ER-CFE was associated with lower 30-day mortality (1.8% vs 3.4%; P = .01), shorter length of stay (median 3 vs 7 days; P < .001), and higher 1-year mortality (8.6% vs 6.3%; P = .04). The two cohorts had equivalent major amputation rate (2.8% vs 2.9%; P = .84). Patients with OR-CFE had greater ABI improvement at long-term follow-up (0.39 ± 0.37 vs 0.26 ± 0.23; P < .001) and were more likely to achieve improved ambulatory status (82% vs 65%; P < .001). CONCLUSIONS: For patients with aortoiliac-femoral occlusive disease, endovascular repair with concomitant CFE appeared to have improved short-term outcomes and equivalent freedom from major amputation compared with open surgical repair with CFE. Conversely, open repair with CFE was associated with better long-term improvement in ABI and ambulatory status. Open repair should therefore be considered for patients with aortoiliac-femoral occlusive disease and reasonable surgical risk.

Outcomes of endovascular aneurysm repair with contemporary volume-dependent sac embolization in patients at risk for type II endoleak.

OBJECTIVE: The aim of this study was to evaluate outcomes of intraoperative aneurysm sac embolization during endovascular aneurysm repair (EVAR) in patients considered at risk for type II endoleak (EII), using a sac volume-dependent dose of fibrin glue and coils. METHODS: Between January 2012 and December 2014, 126 patients underwent EVAR. Based on preoperative computed tomography evaluation of anatomic criteria, 107 patients (85%) were defined as at risk for EII and assigned to randomization for standard EVAR (group A; n = 55, 44%) or EVAR with intraoperative sac embolization (group B; n = 52, 42%); the remaining 19 patients (15%) were defined as at low risk for EII and excluded from the randomization (group C). Computed tomography scans were evaluated with OsiriX Pro 4.0 software to obtain aneurysm sac volume. Freedom from EII, freedom from EII-related reintervention, and aneurysm sac volume shrinkage at 6, 12, and 24 months were compared by Kaplan-Meier estimates. Patients in group C underwent the same follow-up protocol as groups A and B. RESULTS: Patient characteristics, Society for Vascular Surgery comorbidity scores (0.99 ± 0.50 vs 0.95 ± 0.55; P = .70), and operative time (149 ± 50 minutes vs 157 ± 39 minutes; P = .63) were similar for groups A and B. Freedom from EII was significantly lower for group A compared with group B at 3 months (58% vs 80%; P = .002), 6 months (68% vs 85%; P = .04), and 12 months (70% vs 87%; P = .04) but not statistically significant at 24 months (85% vs 87%; P = .57). Freedom from EII-related reintervention at 24 months was significantly lower for group A compared with group B (82% vs 96%; P = .04). Patients in group B showed a significantly overall mean difference in aneurysm sac volume shrinkage compared with group A at 6 months (-11 ± 17 cm(3) vs -2 ± 14 cm(3); P < .01), 12 months (-18 ± 26 cm(3) vs -3 ± 32 cm(3); P = .02), and 24 months (-27 ± 25 cm(3) vs -5 ± 26 cm(3); P < .01). Patients in group C had the lowest EII rate compared with groups A and B (6 months, 5%; 12 months, 6%; 24 months, 0%) and no EII-related reintervention. CONCLUSIONS: This randomized study confirms that sac embolization during EVAR, using a sac volume-dependent dose of fibrin glue and coils, is a valid method to significantly reduce EII and its complications during early and midterm follow-up in patients considered at risk. Although further confirmatory studies are needed, the faster aneurysm sac volume shrinkage over time in patients who underwent embolization compared with standard EVAR may be a positive aspect influencing the lower EII rate also during long-term follow-up.

Aortic hybrid sutureless anastomosis on porcelain aorta.

PURPOSE: To describe a hybrid sutureless anastomosis technique between a prosthetic graft, an endograft, and a circumferentially calcified infrarenal aorta. TECHNIQUE: The technique is demonstrated in a 65-year-old man with flush distal aortoiliac occlusion and patent infrarenal porcelain aorta (IPA). After laparotomy, the IPA was occluded below the renal arteries by inflating an aortic balloon introduced via an axillary access. The IPA was transected in its distal part and aortic thrombectomy performed. A Zenith iliac extension was modified on a back table by cutting the terminal tip; the device was then was inserted and deployed into the IPA in a standard fashion and the sheath removed. A Dacron bifurcated graft was sutured in an end-to-end anastomosis to the endograft and terminal aorta. The 12-month computed tomography scan showed patency of the graft. CONCLUSIONS: This sutureless anastomosis technique seems safe and feasible and represents a valid alternative to standard surgical approaches in cases of heavy and circumferentially calcified infrarenal aorta.