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1.
Artigo em Inglês | MEDLINE | ID: mdl-31603297

RESUMO

INTRODUCTION: The best timing for carotid endarterectomy in patients with stroke is still matter of debate, particularly in case of significant cerebral ischemic lesion or neurological deterioration. The present review and meta-analysis aims to report the best evidence in the outcome of patients submitted to urgent (<48h) or standard elapsing time (<2-week) CEA for stroke and to evaluate the impact of cerebral ischemic lesion size and clinical manifestation in the postoperative outcome. EVIDENCE ACQUISITION: A systematic review and meta-analysis was performed by searching through Scopus and PubMed all papers reporting CEA outcome (stroke and stroke/death) in patients who suffered a stable stroke, treated within 48h and 2 weeks from symptoms. A subgroup analysis of studies reporting the presence and size of cerebral lesion and clinical manifestation was planned. The pooled 30-day stroke and stroke/death risk (effect size) was expressed by crude percentage and 95% confidence interval (CI), by random effect model. EVIDENCE SYNTHESIS: Sixteen studies were included in the meta-analysis, 7 reporting the CEA outcome performed <48h from stroke and 13 reporting the outcome of CEA performed <2-week. The effect size of stroke and stroke/death of CEA performed <48h from symptoms was 7.4% (95% CI: 3.7-11.2) and 7.9% (95% CI: 4.0-11.8) respectively, and for CEA <2-week was 4.5% (95% CI: 2.8- 6.3) and 5.4% (95% CI: 3.4-7.4) respectively. Due to the extremely high heterogeneity of the studies data, the effect size was not calculated, however the authors agreed in considering the severity of stroke and the volume of the cerebral ischemic lesion a risk factor for postoperative complication. Two studies evaluated the effect of the cerebral ischemic lesion distribution; the presence of a border- zone infarct was associated with a significant increase in the risk of post-operative stroke/death rate compared with territorial cerebral ischemic lesion (OR: 6.0; 95%CI 1.1-32.0). CONCLUSIONS: CEA for patients with a recent stroke is associated with 5.4% and 7.9% of stroke/death. A large volume of the cerebral ischemic lesion and a deteriorated neurological status are associated with a higher perioperative risk; urgent carotid revascularization seems to further increase this risk.

2.
Virchows Arch ; 2019 Sep 10.
Artigo em Inglês | MEDLINE | ID: mdl-31506771

RESUMO

Arterial calcification is an actively regulated process, with different morphological manifestations. Micro-RNAs emerged as potential regulators of vascular calcification; they may become novel diagnostic tools and be used for a finest staging of the carotid plaque progression. The present study aimed at characterizing the different miRNA-mRNA axes in carotid plaques according to their histological patterns of calcification. Histopathological analysis was performed on 124 retrospective carotid plaques, with clinical data and preoperatory angio-CT. miRNA analysis was carried out with microfluidic cards. Real-time PCR was performed for selected miRNAs validation and for RUNX-2 and SOX-9 mRNA levels. CD31, CD68, SMA, and SOX-9 were analyzed by immunohistochemistry. miRNA levels on HUVEC cells were analyzed for confirming results under in vitro osteogenic conditions. Histopathological analysis revealed two main calcification subtypes of plaques: calcific cores (CC) and protruding nodules (PN). miRNA array and PCR validation of miR-1275, miR-30a-5p, and miR-30d indicated a significant upregulation of miR-30a-5p and miR-30d in the PN plaques. Likewise, the miRNA targets RUNX-2 and SOX-9 resulted poorly expressed in PN plaques. The inverse correlation between miRNA and RUNX-2 levels was confirmed on osteogenic-differentiated HUVEC. miR-30a-5p and miR-30d directly correlated with calcification extension and thickness at angio-CT imaging. Our study demonstrated the presence of two distinct morphological subtypes of calcification in carotid atheromatous plaques, supported by different miRNA signatures, and by different angio-CT features. These results shed the light on the use of miRNA as novel diagnostic markers, suggestive of plaque evolution.

3.
Ann Vasc Surg ; 2019 Jul 31.
Artigo em Inglês | MEDLINE | ID: mdl-31376538

RESUMO

BACKGROUND: The aim of this study is to evaluate the preliminary outcomes of the Gore® Viabahn® balloon-expandable endoprosthesis (VBX) as bridging stent for fenestrated/branched aortic endograft. METHODS: Between April and June 2018, patients undergoing fenestrated and branched-endovascular aortic repair were prospectively collected. Anatomical, procedural, and postoperative data of patients treated with VBX as bridging stents to connect fenestrations/branches to target visceral vessels (TVVs) were analyzed. Technical success and any TVV-related adverse event were assessed before discharge, at 30 days, and after 6 months of follow-up. RESULTS: Fifteen patients undergoing fenestrated and branched-endovascular aortic repair for juxta/pararenal aneurysms (11), proximal type I endoleak after endovascular aortic repair (1), and thoracoabdominal aneurysms (3) were included in the study. Overall, 60 TVVs-celiac trunk (n = 14), superior mesenteric artery (n = 13), renal arteries (n = 30), hypogastric artery (n = 3)-were accommodated by fenestrations (n = 51), branches (n = 7), and scallops (n = 2). The bridging stent graft was a VBX in 40 (67%) TVVs. A renal artery dissection was successfully managed by a self-expandable bare metal stent. Overall, relining of a bridging stent graft was required in 2 TVVs revascularized by fenestrations (superior mesenteric artery: n = 1, renal artery: n = 1). One intraoperative type III endoleak from renal fenestration was detected and successfully sealed by an adjunctive flaring maneuver. Technical success was achieved in all cases. At 5-day, 1 VBX (1/40: 2.5%) lost its sealing in a renal artery revascularized by a branch (type II thoracoabdominal aortic aneurysm) and required reintervention and relining with a self-expandable stent graft. No TVV occlusion or reintervention occurred <30 days or after 6 months of follow-up. CONCLUSIONS: According to these preliminary results, the Gore Viabahn VBX balloon-expandable endoprosthesis can be safely used as bridging stent graft for fenestrated or branched endografts. A longer follow-up with a larger case load is necessary in order to validate this preliminary experience.

4.
Ann Vasc Surg ; 2019 Aug 06.
Artigo em Inglês | MEDLINE | ID: mdl-31394211

RESUMO

BACKGROUND: Endovascular aneurysm repair (EVAR) is currently accepted as an alternative to open repair for the treatment of abdominal aortic aneurysm (AAA). Approximately 40-60% of AAA patients are not considered eligible for EVAR due to unfavorable anatomy. There is currently no consensus on the definition of "hostile" aortic neck for EVAR procedure. METHODS: An Expert Panel (EP), made up of 9 Italian vascular surgeons from high-volume centers (>50 EVAR procedures/year), was assembled to share their opinion about the definition of hostile aortic neck anatomy for EVAR procedure. The process included a review of the current literature by the EP, a face-to-face meeting, and an on-line survey completed by the EP prior to and following the face-to-face meeting, using the Delphi method. RESULTS: Of the 66 reviewed studies, only 38 (58%) reported at least 1 aortic neck hostility criterion. Five anatomic parameters were identified, namely, aortic neck length, aortic neck angulation, aortic neck diameter, conical neck, and presence of circumferential calcification. Based on the results of the first survey round, these criteria and related definitions were discussed in depth during the face-to-face meeting. For 3 parameters (aortic neck diameter, aortic neck angulation, conical neck), the agreement among the EP members was already high during the first survey round while for the remaining 2 (aortic neck length, circumferential calcification) it remarkably increased from the first to the second survey round. For each of these criteria, as well as combinations of at least 2 of these criteria, specific threshold values were identified above or below which a standard EVAR approach was not considered ideal by the EP due to high/moderate risk of complications. CONCLUSIONS: EP agreed on the definition of 5 aortic neck hostility criteria, according to which they gave their opinion on the feasibility and risks of a standard EVAR approach. Further agreement will be needed and examined on the best nonstandard EVAR technique which may be offered in the presence of different combinations of hostility criteria.

5.
Eur J Vasc Endovasc Surg ; 58(3): 334-342, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31358363

RESUMO

OBJECTIVE: Late distal type I endoleak (ELIB) hampers the outcome of endovascular repair (EVAR) for abdominal aortic aneurysm (AAA); however, only few dedicated experiences have been reported in the literature. The aim of the study was to evaluate the incidence, presentation and treatment of late ELIB and to identify possible anatomical and technical predictors. METHODS: All patients undergoing elective EVAR between 2008 and 2013 were collected prospectively. Follow up was by post-operative computed tomography angiography (CTA) performed within 30 days and CTA and/or duplex ultrasound (DUS) at six or 12 months and yearly thereafter. Patients with late ELIB, defined as distal type I endoleak detected more than six months after the primary intervention without endoleak on the intra-operative completion angiogram and on the post-operative CTA, were retrospectively selected (G1) and compared with a control group with no ELIB (G2) homogeneous for clinical conditions, endograft implanted, and timing of follow up. The minimum follow up required for inclusion in the study was 24 months. Pre-operative morphological aorto-iliac features and EVAR implant details were evaluated, and measurements performed after centre lumen line reconstructions using dedicated software. The differences between G1 and G2 were analysed using the chi-square test, the Student t test, and logistic regression. RESULTS: Six hundred and sixteen patients were submitted to EVAR. ELIB was detected in 14 cases (2.3%) (G1) at a median follow up of 32.8 (IQR 48) months. In three of the 14 cases ELIB was symptomatic (AAA rupture, 2; pain, 1); in the remaining 11 cases it was asymptomatic and found incidentally at routine follow up. Treatment was by open repair in one case and by endovascular iliac leg extension in 13 cases. Hypogastric exclusion was necessary in two of 14 cases. Thirty patients were included in G2, with a median follow up of 41.2 (25) months. Common iliac artery length <4 cm (OR 5.3, 95% CI 1.1-29.5, p = .05), diameter > 15 mm (OR 3.5, 95% CI 1.2-10.9, p = .03), and severe thrombotic apposition (>50% of circumference) (OR 5, 95% CI 1.2-19.2, p = .02), at the iliac sealing zone were significant predictors of ELIB, on univariable analysis; oversizing of the iliac leg diameter < 10% and distal sealing > 1 cm above the hypogastric origin were independently associated with ELIB (OR 5.4, 95% CI 1.3-21.5, p = .01 and OR 6.6, 95% CI 1.1-39.3, p = .03, respectively), on multivariable analysis. CONCLUSION: The present data underline that ELIB is a non-negligible occurrence during long term EVAR follow up and requires further interventions, most often by endovascular solutions. According to the ELIB risk factors identified in this study, an iliac leg diameter oversize >10% and extensive common iliac artery coverage (<1 cm above the hypogastric origin) would be suggested to prevent this complication.

6.
Artigo em Inglês | MEDLINE | ID: mdl-31323677

RESUMO

OBJECTIVES: Our objective was to report the outcomes of fenestrated/branched endovascular aneurysm repair of thoraco-abdominal aortic aneurysms (TAAAs) with endografts. METHODS: Between January 2010 and April 2018, patients with TAAAs, considered at high surgical risk for open surgery and treated by Cook-Zenith fenestrated/branched endovascular aneurysm repair, were prospectively enrolled and retrospectively analysed. The early end points were 30-day/hospital mortality rate, spinal cord ischaemia and 30-day cardiopulmonary and nephrological morbidity. Follow-up end points were survival, patency of target visceral vessels and freedom from reinterventions. RESULTS: Eighty-eight patients (male: 77%; mean age: 73 ± 7 years; American Society of Anesthesiologists 3/4: 58/42%) were enrolled. Using Crawford's classification, 43 (49%) were types I-III and 45 (51%) were type IV TAAAs. The mean aneurysm diameter was 65 ± 15 mm. Custom-made and off-the-shelf endografts were used in 60 (68%) and 28 (32%) cases, respectively. Five (6%) patients had a contained ruptured TAAA. The procedure was performed in multiple steps in 42 (48%) cases. There was 1 (1%) intraoperative death. Five (6%) patients suffered spinal cord ischaemia with permanent paraplegia in 3 (3%) cases. Postoperative cardiac and pulmonary complications occurred in 7 (8%) and 12 (14%) patients, respectively. Worsening of renal function (≥30% of baseline level) was detected in 11 (13%) cases, and 2 (2%) patients required haemodialysis. The 30-day and hospital mortality rates were 5% and 8%, respectively. The mean follow-up was 36 ± 22 months. Survival at 12, 24 and 36 months was 89%, 75% and 70%, respectively. The patency of target visceral vessels at 12, 24 and 36 months was 92%, 92% and 92%, respectively. Freedom from reinterventions at 12, 24 and 36 months was 85%, 85% and 83%, respectively. CONCLUSIONS: The endovascular repair of TAAAs with fenestrated/branched endovascular aneurysm repair is feasible and effective with acceptable technical/clinical outcomes at early/midterm follow-up.

7.
J Vasc Surg ; 69(6S): 3S-125S.e40, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-31159978

RESUMO

Chronic limb-threatening ischemia (CLTI) is associated with mortality, amputation, and impaired quality of life. These Global Vascular Guidelines (GVG) are focused on definition, evaluation, and management of CLTI with the goals of improving evidence-based care and highlighting critical research needs. The term CLTI is preferred over critical limb ischemia, as the latter implies threshold values of impaired perfusion rather than a continuum. CLTI is a clinical syndrome defined by the presence of peripheral artery disease (PAD) in combination with rest pain, gangrene, or a lower limb ulceration >2 weeks duration. Venous, traumatic, embolic, and nonatherosclerotic etiologies are excluded. All patients with suspected CLTI should be referred urgently to a vascular specialist. Accurately staging the severity of limb threat is fundamental, and the Society for Vascular Surgery Threatened Limb Classification system, based on grading of Wounds, Ischemia, and foot Infection (WIfI) is endorsed. Objective hemodynamic testing, including toe pressures as the preferred measure, is required to assess CLTI. Evidence-based revascularization (EBR) hinges on three independent axes: Patient risk, Limb severity, and ANatomic complexity (PLAN). Average-risk and high-risk patients are defined by estimated procedural and 2-year all-cause mortality. The GVG proposes a new Global Anatomic Staging System (GLASS), which involves defining a preferred target artery path (TAP) and then estimating limb-based patency (LBP), resulting in three stages of complexity for intervention. The optimal revascularization strategy is also influenced by the availability of autogenous vein for open bypass surgery. Recommendations for EBR are based on best available data, pending level 1 evidence from ongoing trials. Vein bypass may be preferred for average-risk patients with advanced limb threat and high complexity disease, while those with less complex anatomy, intermediate severity limb threat, or high patient risk may be favored for endovascular intervention. All patients with CLTI should be afforded best medical therapy including the use of antithrombotic, lipid-lowering, antihypertensive, and glycemic control agents, as well as counseling on smoking cessation, diet, exercise, and preventive foot care. Following EBR, long-term limb surveillance is advised. The effectiveness of nonrevascularization therapies (eg, spinal stimulation, pneumatic compression, prostanoids, and hyperbaric oxygen) has not been established. Regenerative medicine approaches (eg, cell, gene therapies) for CLTI should be restricted to rigorously conducted randomizsed clinical trials. The GVG promotes standardization of study designs and end points for clinical trials in CLTI. The importance of multidisciplinary teams and centers of excellence for amputation prevention is stressed as a key health system initiative.

8.
J Endovasc Ther ; 26(4): 550-555, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31140360

RESUMO

Purpose: To evaluate possible predictors of complications with flared iliac stent-graft limbs for ectatic common iliac arteries (CIAs) associated with abdominal aortic aneurysms treated with endovascular aneurysm repair (EVAR). Materials and Methods: A retrospective comparative analysis was conducted of 533 EVAR patients (mean age 75 years; 442 men) treated between 2012 and 2017 who had complications associated with the stent-graft limbs (n=1066). Complications, including type Ib endoleak, type IIIa endoleak, and limb occlusion, were compared between patients with nondilated (<16 mm) CIAs treated with standard iliac limbs (SLs, n=808) vs patients with ectatic CIAs treated with flared limbs (FLs, n=258). Follow-up included a duplex scan at 3, 6, and 12 months and yearly thereafter; computed tomography angiography was performed in case of iliac complications. Risk factors for iliac complications in FLs were investigated using Cox regression and Kaplan-Meier analyses; results of the regression analysis are presented as the hazard ratio (HR) and 95% confidence interval (CI). Results: Overall, no iliac complications occurred at 30 days, but over a mean follow-up of 38±8 months, there were 10 (1%) events (4 limb occlusions, 6 type Ib endoleaks): 7 (3%) in FLs and 3 (0.4%) in SLs (p=0.20). Kaplan-Meier analysis found no differences at 5 years in SLs vs FLs for freedom from limb occlusion (99%±1% vs 98%±1%, respectively; p=0.30) or type Ib endoleak (96%±3% vs 97%±1%, respectively; p=0.44). Similarly, the overall 5-year iliac complication rates were similar in SLs vs FLs (96%±3% vs 95%±2%, p=0.21). Regression analysis found CIA length ≤30 mm (HR 4.7, 95% CI 1.02 to 21.6, p=0.04) and a diameter ≥20 mm (HR 7.8, 95% CI 1.05 to 64.8, p=0.03) to be independent predictors of iliac complications in FLs. Kaplan-Meier estimates of iliac complication-free survival in FLs were significantly worse when the CIA length was ≤30 mm (79%±9% vs 98%±1%, p=0.003) or the diameter was ≥20 mm (85%±7% vs 99%±1%, p=0.02). The combination of both risk factors produced significantly poorer iliac complication-free survival compared with cases in which there was one or no risk factor (67%±19% vs 96%±2% vs 99%±1%, respectively; p<0.001). Conclusion: Iliac limb complications are infrequent in EVAR, regardless of the type of iliac limb chosen; however, CIAs ≤30 mm in length or ≥20 mm in diameter significantly increased the risk of late iliac complications in FLs. If both characteristics were present, this risk was further elevated.

9.
Ann Vasc Surg ; 59: 102-109, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31009717

RESUMO

BACKGROUND: Fenestrated/branched endografts for aortic repair (FB-EVAR) are valid options to treat thoracoabdominal aortic aneurysms (TAAAs). Successful repair requires manipulation of target visceral vessels (TVVs) with possible splanchnic ischemia. The aim of the study was to evaluate the clinical impact of splanchnic ischemia occurring in FB-EVAR for TAAA. METHODS: Between 2010 and 2015, patients with TAAAs undergoing FB-EVAR were prospectively enrolled. Clinical, morphological, procedural, and 30-day data were evaluated. Splanchnic ischemia was defined as the presence of splanchnic ischemic lesions (SILs) visible at perioperative computed tomography angiography. Preoperative, postoperative, and 30-day hepatic/pancreatic/renal laboratory functions were analyzed. End points were incidence of SILs, laboratory splanchnic functions worsening (≥25% of baseline), and presence of related clinical/morphological and procedural risk factors. RESULTS: Thirty-six patients (male: 78%; age: 73 ± 7 years) with 27 (75%) type I-III and 9 (25%) type IV TAAA who underwent FB-EVAR for a total of 127 TVV (branches: 47-60%; fenestrations: 53-67%). Fourteen SILs occurred in 12 (33%) patients: 4 (29%) in pancreas, 3 (21%) in spleen, 2 (14%) in bowel, 5 (36%) in kidney. The cause was embolic in 79% and thrombotic in 21%. No preoperative clinical/morphological data or procedural data were correlated with SIL. Pancreatic, hepatic, or renal function worsening occurred at 24 hr in 16 (44%), 16 (44%), and 9 (25%) cases, respectively. Overall, SILs were associated with increased values of C-reactive protein (CRP) (17.9 ± 0.4 vs. 9.9 ± 9.0 mg/dL; P = 0.03) and bilirubin (1.2 ± 2.3 vs. 1.0 ± 0.5 mg/dL; P = 0.02) at 24 hr. Specifically, SIL of the celiac trunk and superior mesenteric and renal arteries' parenchyma were associated with the significant laboratory function changes 24 hr. SIL of the superior mesenteric artery was associated with increased 30-day mortality (50% vs. 7 %; P = 0.002). Pancreatic, hepatic, or renal function worsening occurred at 30 days in 2 (6%), 0 (0%), and 4 (12%) cases, with similar laboratory tests in patients with and without SIL. CONCLUSIONS: SIL can be frequently detected after FB-EVAR for TAAA and appears mainly of embolic origin. No clinical, morphological, or procedural predictors could be identified in our series. Postoperative laboratory changes of CRP, bilirubin, activated partial thromboplastin time, and amylases are associated with SIL but disappear without clinical consequences within 30 days. However, SIL occurring in the superior mesenteric artery are associated with an increased 30-day mortality.


Assuntos
Aneurisma da Aorta Torácica/cirurgia , Implante de Prótese Vascular/efeitos adversos , Implante de Prótese Vascular/instrumentação , Prótese Vascular , Embolia/etiologia , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/instrumentação , Artéria Mesentérica Superior/fisiopatologia , Isquemia Mesentérica/etiologia , Oclusão Vascular Mesentérica/etiologia , Circulação Esplâncnica , Idoso , Idoso de 80 Anos ou mais , Aneurisma da Aorta Torácica/mortalidade , Aneurisma da Aorta Torácica/fisiopatologia , Implante de Prótese Vascular/mortalidade , Angiografia por Tomografia Computadorizada , Bases de Dados Factuais , Embolia/diagnóstico por imagem , Embolia/mortalidade , Embolia/fisiopatologia , Procedimentos Endovasculares/mortalidade , Feminino , Humanos , Masculino , Artéria Mesentérica Superior/diagnóstico por imagem , Isquemia Mesentérica/diagnóstico por imagem , Isquemia Mesentérica/mortalidade , Isquemia Mesentérica/fisiopatologia , Oclusão Vascular Mesentérica/diagnóstico por imagem , Oclusão Vascular Mesentérica/mortalidade , Oclusão Vascular Mesentérica/fisiopatologia , Estudos Prospectivos , Desenho de Prótese , Fatores de Risco , Trombose/etiologia , Trombose/fisiopatologia , Fatores de Tempo , Resultado do Tratamento
10.
J Vasc Surg ; 70(3): 901-912, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-30922745

RESUMO

OBJECTIVE: The revascularization of critical limb ischemia (CLI) in hemodialysis (HD) patients features poor results in terms of patient survival and limb salvage. Recent predictive models in CLI revascularization did not specifically address HD patients. The aim of this study was to define risk factors for clinical success (CS) after revascularization of CLI in HD patients and to transform findings in a prognostic score. METHODS: A retrospective study was conducted of prospectively gathered data, including consecutive HD patients treated for CLI from January 2004 to December 2012. Patients' demographics, comorbidities, CLI stage (Rutherford classification), tissue loss (Texas University Wound classification [TUWC]), and type of revascularization were assessed. End points were CS after revascularization (amputation-free and reintervention-free survival) and a prognostic score for CS based on significant risk factors (multivariable analysis). RESULTS: In the study period, 131 patients (mean age, 70.2 ± 9.9 years; male, 76.3%) with a total of 180 limbs were treated. Endovascular (52.8%), surgical (28.9%), or hybrid (10.6%) revascularization was performed in 163 (90.6%) limbs in 117 patients. The mean (± standard deviation) follow-up was 20.8 ± 21.1 months. Considering revascularized patients, CS was 47.9%, 30.8%, and 17.8% at 6, 12, and 24 months, respectively. On multivariable analysis, age (hazard ratio [HR], 1.03; 95% confidence interval [CI], 1.01-1.05; P = .005), coronary artery disease (CAD; HR, 1.55; 95% CI, 1.04-2.32; P = .032), and TUWC stage D (HR, 1.80; 95% CI, 1.22-2.67; P = .003) were independent negative factors. Type of revascularization had no influence on CS. The score for predicting CS was 0.026 × age (years) + 0.441 × CAD + 0.59 × TUWC stage D. CAD and TUWC stage D were 1 in the presence of disease and 0 in the absence of disease. The score has a significant discrimination power of 75.5% (P = .036), with a best cutoff value of 2.07. Patients with a CS score <2.07 would have a low risk of clinical failure, whereas patients with a CS score >2.07 would have a high risk. There were 31 (26.5%) cases of low-risk score and 86 (73.5%) cases of high-risk score. Cases with low-risk score had a CS at 1 year of 51.6% compared with 23.3% in cases with high-risk score. CONCLUSIONS: CS after revascularization in HD patients remains poor independent of the type of revascularization. A prognostic model based on age, history of CAD, and severity of CLI (TUWC stage D lesion) can estimate an individual's chances of CS and may help in the decision-making process.

11.
J Vasc Interv Radiol ; 30(4): 503-510, 2019 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-30910172

RESUMO

PURPOSE: To compare perioperative and long-term outcomes of endovascular aneurysm repair (EVAR) with flared limbs (FLs) vs iliac branch devices (IBDs) for common iliac artery aneurysm to determine possible differences in outcome. MATERIALS AND METHODS: From 2012 to 2017, all patients with standard EVAR with FLs and aortoiliac anatomy fit for implantation of IBDs were retrospectively selected and compared with patients with standard EVAR and IBDs. The study included 150 patients with 162 iliac treatments: 105 (65%) FLs and 57 (35%) IBDs. Iliac complications (ICs), including internal iliac artery (IIA) loss, limb thrombosis, and type 1b or type 3 endoleak, were considered at 30 days and in the follow-up period. RESULTS: Procedural time and volume of contrast medium were significantly higher in IBD vs FL procedures (90 min ± 33 vs 70 min ± 25, P = .01; 130 mL ± 40 vs 80 mL ± 20, P = .01). Perioperative rate of ICs was similar between IBDs and FLs (0% vs 3.8% [4 IIA loss], P = .25). During 35-month median follow-up, there were 10 ICs, all in FLs group (4 IIA perioperative loss, 4 type 1b endoleak, 2 limb occlusion). By Kaplan-Meier analysis, survival free of ICs was significantly higher in IBD group after 4 years of follow-up (1 y 100% vs 96%, P = .36; 2 y 100% vs 94%, P = .14; 3 y 100% vs 91%, P = .07; 4 y 100% vs 87%, P = .03; 5 y 100% vs 78%, P = .02). CONCLUSIONS: IBDs and FLs have similar perioperative results. IBDs require longer procedural time and greater contrast medium volume; however, they are associated with lower ICs after 4 years of follow-up.

12.
Ann Vasc Surg ; 58: 211-221, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-30763709

RESUMO

BACKGROUND: To report perioperative and 1-year results of total endovascular repair of contained ruptured thoracoabdominal aortic aneurysms (TAAAs). METHODS: Between 2015 and 2017, preoperative, procedural, and postoperative data of patients with radiographic evidence of contained ruptured TAAAs treated by endovascular repair were prospectively collected. Only patients with stable hemodynamic parameters were enclosed. Primary endpoints were 30-day/in-hospital mortality, spinal cord ischemia (SCI), postoperative cardiopulmonary complications, and new onset of hemodialysis. Secondary endpoints were endoleaks, reinterventions, and overall follow-up survival. RESULTS: Twelve patients underwent endovascular repair for contained ruptured TAAAs. According with the Crawford/Safi's classification, 6 type II (50%), 3 type III (25%), 1 type IV (8%), and 2 type V (17%) TAAAs were treated. All patients were symptomatic. Overall, 34 target visceral vessels were planned to be revascularized. The mean time from admission to treatment was 48 hours (range 4-96), with 4 patients operated within 24 hours. Five patients (42%) were treated by T-branch, 3 (25%) by custom-made fenestrated/branched endografts, 3 (25%) by parallel graft technique, and 1 (8%) by standard thoracic endovascular aortic repair covering a stenotic celiac trunk. The 30-day and in-hospital mortality was 17% and 25%, respectively. Two patients (17%) developed SCI. Cardiac and pulmonary complications were reported in 1 (8%) and 3 (25%) cases, respectively. One patient (8%) needed permanent hemodialysis. Two endoleaks (17%) were detected at the postoperative computed tomography angiography (1 low-flow gutter endoleak and 1 type III endoleak). Four patients (33%) required re-interventions within 30 postoperative days. The mean follow-up was 12 months (range 1-22). No late target visceral vessels occlusion, endoleak, or reintervention occurred in this series. Overall, 7/12 (59%) patients were alive, and no cases of TAAA-related mortality occurred during follow-up. CONCLUSIONS: According to our results, endovascular repair of contained ruptured TAAAs is feasible by a flexible approach in selected patients with anatomical suitability and stable hemodynamic conditions. Although early mortality and morbidity are significant, with frequent reintervention necessity, subsequent follow-up is free from reinterventions and TAAA-related mortality.


Assuntos
Aneurisma da Aorta Torácica/cirurgia , Ruptura Aórtica/cirurgia , Implante de Prótese Vascular , Procedimentos Endovasculares , Idoso , Idoso de 80 Anos ou mais , Aneurisma da Aorta Torácica/diagnóstico por imagem , Aneurisma da Aorta Torácica/mortalidade , Aneurisma da Aorta Torácica/fisiopatologia , Ruptura Aórtica/diagnóstico por imagem , Ruptura Aórtica/mortalidade , Ruptura Aórtica/fisiopatologia , Aortografia/métodos , Prótese Vascular , Implante de Prótese Vascular/efeitos adversos , Implante de Prótese Vascular/instrumentação , Implante de Prótese Vascular/mortalidade , Angiografia por Tomografia Computadorizada , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/instrumentação , Procedimentos Endovasculares/mortalidade , Feminino , Hemodinâmica , Mortalidade Hospitalar , Humanos , Masculino , Duração da Cirurgia , Complicações Pós-Operatórias/mortalidade , Complicações Pós-Operatórias/terapia , Estudos Prospectivos , Desenho de Prótese , Fatores de Risco , Stents , Fatores de Tempo , Resultado do Tratamento
14.
J Vasc Surg ; 2018 Nov 23.
Artigo em Inglês | MEDLINE | ID: mdl-30477940

RESUMO

OBJECTIVE: The appropriateness of endovascular aneurysm repair (EVAR) of uncomplicated abdominal aortic aneurysm depends on the risk-benefit ratio, particularly in elderly patients with short life expectancy. The aim of this study was to assess the efficacy of EVAR in >80-year-old patients by evaluating their postoperative survival and analyzing the possible predictors of late mortality. METHODS: All consecutive patients aged >80 years undergoing elective EVAR from 2006 to 2015 were prospectively evaluated. The 30-day mortality and long-term survival were assessed, and independent risk factors for mortality were determined by multivariate logistic and Cox analysis. RESULTS: Of a total of 1135 EVARs performed in a 10-year period, 201 (18%) occurred in patients older than 80 years. The median age was 84 years (interquartile range, 3 years), and 85% were male. Thirty-four patients (17%) had a score of 4 according to the American Society of Anesthesiologists (ASA) classification. Overall 30-day mortality was 2% (n = 4); it was significantly higher in those with ASA score of 4 compared with ASA score <4 (9.4% vs 0.6%; P = .04) and was also confirmed by multivariate analysis (odds ratio, 12.7; 95% confidence interval [CI], 1.1-141.8; P = .04). The mean follow-up was 36 ± 18 months, and the overall survival at 1 year, 3 years, and 5 years was 85% ± 2%, 77% ± 3%, and 52% ± 4%, respectively. Using multivariate Cox regression, ASA score of 4 and peripheral artery obstructive disease (PAOD) were the only independent predictors for midterm mortality (hazard ratio of 2.0 [95% CI, 1.2-2.9; P = .04] and 3.07 [95% CI, 1.06-5.2; P = .04], respectively). The 2-year survival was significantly influenced by the presence of both (ASA score of 4 and PAOD; survival, 33% ± 2%) or one (ASA score of 4 or PAOD; survival, 67% ± 8%) of the two independent predictors. If neither ASA score of 4 nor PAOD was present, survival was significantly improved (92% ± 3%; P = .02). CONCLUSIONS: The performance of EVAR in >80-year-old patients is associated with an overall early mortality rate as low as 2%. In patients with no or only one risk factor, the survival rate warrants the treatment of abdominal aortic aneurysm; in contrast, patients with ASA score of 4 and PAOD have a significantly higher mortality rate and reduction of life expectancy.

15.
Int Angiol ; 37(5): 384-389, 2018 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-30203639

RESUMO

BACKGROUND: To report early and mid-term results of endovascular treatments for type Ib endoleaks (IbEL) after endovascular aneurysm repair (EVAR) for aorto-iliac aneurysms (AAA). METHODS: Patients with IbEL after EVAR were retrospectively analyzed. Cases of IbEL treated in two centers from January 2009 to February 2017 were considered. Patients' demographics and comorbidities, interval between EVAR and IbEL diagnosis, type of endograft, site of sealing, oversize and length of iliac sealing zone, type of IbEL treatment were collected. Main endpoints were freedom from IbEL recurrence and freedom from reintervention. RESULTS: Thirty-five IbEL were treated in 29 patients (mean age: 76±7years; male: 100%). Mean time between EVAR and IbEL detection was 43±30months. IbEL was symptomatic in 4 (14%) and bilateral in 6 (21%). Endograft was bifurcated in 26 patients (90%) and aorto-uniiliac in 3 (10%). Distal landing zone was achieved in common and external iliac artery in 33 (94%) and 2 cases (6%), respectively. Mean oversize of endograft limb was 11±9%, mean length of sealing zone was 22±15 mm. Endovascular treatments included: 34 iliac extensions (8 cases [24%] with hypogastric artery coverage), and 1 embolization. Concomitant embolization of hypogastric artery was performed in 3 (9%) cases. Technical success was 100%, with no procedure-related complication. Considering patients with hypogastric exclusion, buttock claudication developed in 2/8 cases (25%). Mean follow-up was 20±19 months. Freedom from IbEL was 100% and no reintervention was necessity for IbEL during follow-up. At 12, 24 and 36 months, survival was 88%, 82% e 61%, respectively, with no IbEL-related death. CONCLUSIONS: IbEL can be easily managed by endovascular means, typically with distal extensions with landing zones in the common or external iliac artery. Mid-term results are favourable, with no recurrent IbEL or reintervention.

16.
Vascular ; : 1708538118799225, 2018 Sep 07.
Artigo em Inglês | MEDLINE | ID: mdl-30193550

RESUMO

Objective Carotid stenosis with crescendo-transient-ischemic-attack (cTIA) requires a prompt intervention to reduce the stroke risk. Few data are reported in literature about cTIA suggesting a different perioperative risk compared with patients with single TIA (sTIA). This study aimed to compare the outcome of carotid endarterectomy (CEA) in patients with TIA (single/crescendo) and evaluate the outcome risk-factors. Methods Data from two tertiary hospitals for vascular treatment were analyzed from 2007 to 2016. All patients with TIA subjected to CEA were considered, comparing the 30-day postoperative stroke and stroke/death in patients with cTIA and sTIA, particularly in the urgent (≤48 h) setting. Results On a total of 3866 CEA, 888 (23%) were performed in symptomatic patients and 515 for TIA: 365 (71%) patients with sTIA and 150 (29%) with cTIA. When compared with sTIA, cTIA patients were younger and less frequently affected by coronary disease, dyslipidemia, and chronic pulmonary disease; however, contralateral carotid occlusion was more common (20% vs. 10%, P = .004; 56% vs. 46, P = .03; 16% vs. 7%, P = .01; >80 years 26% vs. 16%, P = .01 and 2% vs. 10%, P = .001; respectively). Postoperative stroke and stroke/death were significantly higher in cTIA compared with sTIA (5.3% vs. 1.6%, P = .02 and 6.0% vs. 2.2%, P = .03; respectively). Urgent CEA was performed in 58% ( n: 87) cTIA and in 11% ( n: 56) sTIA( P<.01). The urgent setting did not influence the stroke and stroke/death rate of CEA for sTIA (3.6% vs. 1.3%, P = .21 and 3.6% vs. 1.9%, P = .44, respectively), but was associated with lower rate of events in cTIA (1.1%vs. 11.1%, P = .01 and 2.3% vs. 11.1%, P = .03, respectively). This beneficial effect in patients with cTIA treated within 48-h was confirmed also by multivariate analysis (OR: 0.09, 95% CI: 0.76-0.01, P=.02). Conclusions cTIA subjected to CEA have a higher stroke and stroke/death risk compared with patients with sTIA. The urgent setting seems to reduce the stroke/death rate cTIA; for sTIA with a stable neurological condition, the timing of CEA did not influence the outcome.

17.
Artigo em Inglês | MEDLINE | ID: mdl-30160093

RESUMO

Improvements in endovascular technologies and development of custom-made fenestrated and branched endografts currently allow clinicians to treat complex aortic lesions such as thoraco-abdominal and aortic arch aneurysms once treatable with open repair only. These advances are leading to an increase in the complexity of endovascular procedures which can cause long operation times and high levels of radiation exposure. This in turn places pressure on the vascular surgery community to display more superior interventional skills and radiological practices. Advanced imaging technology in this context represents a strong pillar in the treatment toolbox for delivering the best care at the lowest risk level. Delivering the best patient care while managing the radiation and iodine contrast media risks, especially in frail and renal impaired populations, is the challenge aortic surgeons are facing. Modern hybrid rooms are equipped with a wide range of new imaging applications such as fusion imaging and cone-beam computed tomography (CBCT). If these technologies contribute to reducing radiation, they can be complex and intimidating to master. The goal of this review is to discuss the fundamentals of good radiological practices and to describe the various imaging tools available to the aortic surgeon, both those available today and those we anticipate will be available in the near future, from equipment to software, to perform safe and efficient complex endovascular procedures.

18.
J Vasc Surg ; 2018 Aug 17.
Artigo em Inglês | MEDLINE | ID: mdl-30126779

RESUMO

OBJECTIVES: We report a multicenter experience of urgent late open conversion (LOC), with the goal of identifying the mode of presentation, technical aspects, and outcomes of this cohort of patients. METHODS: A retrospective analysis of endovascular aneurysm repair (EVAR) requiring LOC (>30 days after implantation) from 1996 to 2016 in six vascular centers was performed. Patients with aneurysm rupture or other conditions requiring urgent surgery (<24 hours) were included. Patient demographics, time interval between EVAR and LOC, endograft characteristics, previous attempts at endovascular correction, indications, operative technique, 30-day mortality and morbidity, and long-term survival were analyzed. RESULTS: There were 42 patients (88.1% men; mean age, 75.8 ± 9.0 years) included. Among the 42 explanted grafts, 33 were bifurcated, 1 tube, 6 aortouni-iliac, and 2 side-branch devices. Suprarenal fixation was present in 78.6%. Twelve patients (28.6%) underwent endovascular reintervention before LOC. Indications for urgent LOC were aneurysm rupture in 24 of the 42 cases (57.1%), endograft infection in 11 (26.2%), endoleak associated with aneurysm growth and pain in 6 (14.3%), and recurrent endograft thrombosis in 2 (4.8%). The proximal aortic cross-clamping site was infrarenal in 38.1% of cases, suprarenal in 19.1%, and supraceliac in 42.9%. Complete removal of the endograft was performed in 32 patients (76.2%) and partial removal in 10 (proximal preservation in 7 of 10). Reconstructions were performed with Dacron grafts in 33 of the 42 cases, cryopreserved arterial allografts in 5, and endograft removal associated with prosthetic axillobifemoral bypass in 4. The 30-day mortality was 23.8%; hemorrhagic shock was an independent risk factor of early mortality (odds ratio, 10.5; 95% confidence interval, 1.5-73.7; P = .018). During a mean follow-up of 23.9 ± 36.0 months, two late aneurysm-related deaths occurred. The estimated 1- and 5-year survival rates were 62.1% and 46.1%, respectively. CONCLUSIONS: Urgent LOC after EVAR are associated with high postoperative mortality rates and poor long-term survival. Further studies are necessary to define the timing and the best treatment option for failing EVAR.

19.
Eur J Vasc Endovasc Surg ; 56(3): 382-390, 2018 09.
Artigo em Inglês | MEDLINE | ID: mdl-30072297

RESUMO

OBJECTIVE: To evaluate the impact of renal artery (RA) anatomy on the renal outcome of fenestrated-branched endografts (FB-EVAR) for thoraco-abdominal aortic aneurysms (TAAA). METHODS: Between 2010 and 2016, all patients undergoing FB-EVAR for TAAA were prospectively collected. Anatomical, procedural, and post-operative data were retrospectively analysed. RA anatomy was assessed on volume rendering, multi planar and centre line reconstructions by dedicated software (3Mensio). RA diameter, length, ostial stenosis/calcification, orientation and aortic angles of the para-visceral aorta were evaluated. RA orientation was classified in four types: A (horizontal), B (upward), C (downward), D (downward + upward). RA revascularisation by fenestrations or branches was considered. Inability to cannulate and stent RA (RA loss), early RA occlusion (within three months), and composite RA events (one among RA loss, intra-operative RA lesion, RA related re-interventions, RA occlusion) were assessed. RESULTS: Seventy-three patients (male 77%; age 73 ± 6 years) with 39 (53%) type I, II, III and 34 (47%) type IV TAAA, underwent FB-EVAR, for a total of 128 RAs. The mean RA diameter and length were 6 ± 1 mm and 43 ± 12 mm, respectively. Type A, B, C, and D orientations were 51 (40%), 18 (14%), 48 (36%), and 11 (10%) RAs, respectively. Angulation of para-visceral aorta >45° was present in 14 cases (19%). Ostial stenosis and calcifications were detected in 20 (16%) and 16 (13%) RAs, respectively. Branches and fenestrations were used in 43 (34%) and 85 (66%) RAs, respectively. There were four (3%) intra-operative RA lesions (2 ruptures, 2 dissections). Ten (8%) RAs were lost intra-operatively because of the inability to cannulating and stenting. On univariable analysis, type B RA orientation (p = .001; OR 13.2; 95% CI 3.2-53.6), para-visceral aortic angle > 45° (p = .02; OR 4.9; 95% CI 1.3-18.5) and branches (p = .003; OR 9.0; 95% CI 1.9-46.9) were risk factors for intra-operative RA loss; type C RA orientation was a protective factor (p = .02; OR 0.1; 95% CI 0.01-0.9). On multivariable analysis, type B RA orientation (p = .03; OR 5.9; 95% CI 1.1-31.1) and branches (p = .03; OR 7.3; 95% CI 1.1-47.9) were independent risk factors for intra-operative RA loss. Fourteen patients suffered post-operative renal function worsening (> 30% of the baseline). The mean follow up was 19 ± 12 months. Four (3%) early RA occlusions occurred in three patients (2 single kidney patients required permanent haemodialysis). Type D RA orientation (p = .00; RR 17.8; 8.6-37.0) and branches (p = .004; RR 3.2; 2.4-4.1) were risk factors for early RA occlusion on univariable analysis. Five patients (7%) required early RA related re-interventions (recanalisation + relining 3; stent graft extension 1; parenchymal embolisation 1). No late RA occlusion or re-interventions were reported during follow up. Composite RA events occurred in 17 (13%) cases. Type B (p = .05; OR 3.9; 95% CI 1.1-15.7) or D (p = .006; OR 10.9; 95% CI 2.3-50.8) RA orientations and branches (p = .006; OR 5.7; 95% CI 1.6-20.3) were independent predictors of composite RA events on multivariable analysis. CONCLUSION: Renal artery orientation significantly affects the early RA outcome of FB-EVAR for TAAA. Intra-operative RA loss is predicted by type B RA orientation and branches, while early RA occlusion is predicted by type D orientation and branches. The present data suggest that in TAAA, fenestrations should be the first choice for renal revascularisation in type B and D RA orientations.


Assuntos
Aneurisma da Aorta Abdominal/cirurgia , Aneurisma da Aorta Torácica/cirurgia , Implante de Prótese Vascular , Procedimentos Endovasculares , Obstrução da Artéria Renal/cirurgia , Artéria Renal/cirurgia , Calcificação Vascular/cirurgia , Idoso , Aneurisma da Aorta Abdominal/diagnóstico por imagem , Aneurisma da Aorta Abdominal/fisiopatologia , Aneurisma da Aorta Torácica/diagnóstico por imagem , Aneurisma da Aorta Torácica/fisiopatologia , Aortografia/métodos , Prótese Vascular , Implante de Prótese Vascular/efeitos adversos , Implante de Prótese Vascular/instrumentação , Angiografia por Tomografia Computadorizada , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/instrumentação , Feminino , Humanos , Masculino , Análise Multivariada , Razão de Chances , Desenho de Prótese , Artéria Renal/diagnóstico por imagem , Artéria Renal/fisiopatologia , Obstrução da Artéria Renal/diagnóstico por imagem , Obstrução da Artéria Renal/fisiopatologia , Estudos Retrospectivos , Fatores de Risco , Stents , Fatores de Tempo , Resultado do Tratamento , Calcificação Vascular/diagnóstico por imagem , Calcificação Vascular/fisiopatologia , Grau de Desobstrução Vascular
20.
Ann Vasc Surg ; 53: 154-164, 2018 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-29886216

RESUMO

BACKGROUND: The aim of the study was to evaluate the outcomes of duplex ultrasonography (DUS)-guided autologous vein bypass to paramalleolar (distal third of tibial arteries and peroneal artery) and inframalleolar arteries (dorsalis pedis, common plantar, medial, and lateral plantar arteries) in patients with critical limb ischemia (CLI) and extensive tibial artery disease Trans-Atlantic Inter-Society Consensus D. METHODS: Between January 2007 and October 2016, all paramalleolar or inframalleolar bypasses performed in patients with CLI, planned only on the basis of DUS, were collected and analyzed retrospectively. DUS evaluation included arterial disease extension, inflow and outflow arteries' diameter, outflow vessels resistance, and autologous veins quality. Patient's demographics and clinical characteristics were assessed. Tissue loss was graded according to Texas University Wound Classification (TWC). Follow-up included periodic clinical and DUS examinations. Primary end points were technical success (TS) (patent bypass with distal anastomosis performed on the Duplex-selected runoff artery, without stenosis >30% and in line flow with the inframalleolar arteries at completion angiography and without hemodynamic bypass stenosis at postoperative DUS) and bypass patency (primary [PP], assisted [AP], and secondary [SP]). Secondary end points were perioperative and follow-up patient survival (PS), limb salvage (LS), and amputation-free survival (AFS). Descriptive statistics and Kaplan-Meier analysis were performed. Univariate and Multivariate Cox analyses were used to define risk factors. RESULTS: Seventy-four bypasses in 73 patients with CLI (Rutherford 5-6 93.2%, TWC stage III in 63.5% and grade D in 48.6%) were performed in the study period (January 2007-October 2016). diabetes mellitus, coronary artery disease, and kidney disease were present in 67.6%, 60.8%, and 37.8% patients, respectively. Distal anastomosis was performed at the paramalleolar and inframalleolar arteries in 47.3% and 52.7%, respectively. Only autologous veins were used as conduit. TS was 98.6%. At 1-month, PP, AP, SP, PS, LS, and AFS were 87.8%, 91.9%, 93.2%, 95.9%, 94.6%, and 90.5%, respectively. The mean follow-up was 33.7 months; at 1-year, PP, AP, SP, PS, LS, and AFS were 54.4%, 71.4%, 75.1%, 89.9%, 84.3%, and 79.1%, respectively, and at 3-year, 42.3%, 63%, 66%, 67.5%, 80.6%, and 61%, respectively. At univariate and multivariate analyses, arterial hypertension was protective for PP (P = 0.035) while insulin-dependent diabetes was a negative predictor (P = 0.01); insulin-dependent diabetes was a negative predictor of LS (P = 0.002); TWC grade D was a negative predictor of AP (P = 0.047) and SP (P = 0.013). Age (P < 0.001) and major amputation (P = 0.014) resulted as negative predictors of PS. CONCLUSIONS: Bypass of the Duplex-selected paramalleolar and inframalleolar arteries in CLI has high TS and high rate of perioperative and late LS. Duplex evaluation and planning in CLI patients with extensive tibial arteries disease is associated with efficacy of surgical revascularization and high LS rates.

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