Failure of Sandwich Technique for Thoracoabdominal Aneurysm Treated with Custom-Made Fenestrated Endograft.

BACKGROUND: Custom-made fenestrated and branched endografts are considered the gold standard devices for thoracoabdominal repair, with lower perioperative mortality and morbidities than open surgical repair. Although they are not feasible in urgent and emergent settings, in which sandwich techniques are often necessary, custom-made devices can still be used as bail-out options to correct late complications such as high-flow endoleaks, as shown in this case report. METHODS: A complex, symptomatic thoracoabdominal aneurysm, unsuitable for open repair, was treated by sandwich technique on the celiac trunk despite having a short distal neck. After the finding of a high-flow type IB endoleak during postoperative follow-up, reintervention was planned with a custom-made endograft with a distal scallop, to preserve patency of the superior mesenteric artery. RESULTS: The procedure achieved technical success, with complete exclusion of the aneurysm and patency of all the visceral arteries. CONCLUSIONS: Bail-out endovascular repair with custom-made endografts after failure of parallel graft repair of thoracoabdominal aneurysms is a valuable treatment option preventing the risks related to an open conversion.

The Bolton Treo Endograft: A Single-Center Preliminary Experience.

BACKGROUND: Endovascular repair is currently the most frequently used treatment of abdominal aortic aneurysms, but its feasibility and success highly depend on the characteristics and the correct choice of the endograft to be used. Bolton Treo is one of the most popular endografts of newer generation which have been launched in the past few years, and this study aims to analyze the preliminary outcomes (8 months in average) of a single-center experience with this device. METHODS: Thirty-seven consecutive abdominal aortic aneurysms, treated with Treo between June 2016 and December 2017, were followed up every 3, 6, and 12 months, and any kind of endograft-related complications was recorded. RESULTS: Technical success was 100%, and no perioperative death (within 30 days) was recorded. Over a mean follow-up period of 8 months, the overall reintervention rate was 5.4% (2 cases, for a type Ia endoleak and an iliac branch thrombosis), for those performed by endovascular techniques. Two type II endoleaks, not worthy of treatment, were also observed. No procedure-related mortality, endograft thrombosis, or rupture was observed. CONCLUSIONS: Over the short term, Treo demonstrated high effectiveness in treating abdominal aortic aneurysms both in elective and urgent settings, within and outside the indications for use. Outcomes over long term are still needed to validate these results.

Emergent Endovascular Treatment of Thoracoabdominal Aortic Rupture in Behcet's Disease.

BACKGROUND: Aortic rupture in Behcet's disease is associated with high mortality rates. Endovascular approach with parallel graft technique can be a valid solution in emergency setting for the treatment of thoraco-abdominal aorta involvement in Behcet's disease. METHODS: We describe the clinical case of a 41-year-old man, urgently hospitalized for a rupture of thoraco-abdominal aorta with occlusion of the celiac trunk and involvement of superior mesenteric artery. The patient also presented a massive right hemothorax and a massive left pulmonary thromboembolism. An aortic endoprosthesis was deployed from the third bottom of the thoracic aorta to the origin of the renal arteries. Parallel stent-graft technique was used to preserve the patency of the superior mesenteric artery. The procedure was performed with local anaesthesia due to the critical conditions of the patient. The patient was discharged in good clinical conditions. RESULTS: The angio-computed tomography performed 6 months after surgery showed good deployment of the endoprosthesis and patency of the superior mesenteric artery. CONCLUSION: In high risk for surgery patients, endovascular treatment with parallel stent graft of thoraco-abdominal aorta rupture is safe and feasible.

Early and mid-term results in the endovascular treatment of popliteal aneurysms with the multilayer flow modulator.

Background The endovascular approach became an alternative to open surgical treatment of popliteal artery aneurysm over the last few years. Heparin-bonded stent-grafts have been employed for endovascular popliteal artery aneurysm repair, showing good and stable results. Only few reports about the use of multilayer flow modulator are available in literature, providing small patient series and short follow-up. The aim of this study is to report the outcomes of patients with popliteal artery aneurysm treated with the multilayer flow modulator in three Italian centres. Methods We retrospectively analysed a series of both symptomatic and asymptomatic patients with popliteal artery aneurysm treated with the multilayer flow modulator from 2009 to 2015. Follow-up was undertaken with clinical and contrast-enhanced ultrasound examinations at 1, 6 and 12 months, and yearly thereafter. Computed tomography angiography was performed in selected cases. Primary endpoints were aneurysm sac thrombosis; freedom from sac enlargement and primary, primary-assisted and secondary patency during follow-up. Secondary endpoints were technical success, collateral vessels patency, limb salvage and aneurysm-related complications. Results Twenty-three consecutive patients (19 males, age 72 ± 11) with 25 popliteal artery aneurysms (mean diameter 23 mm ± 1, 3 symptomatic patients) were treated with 40 multilayer flow modulators during the period of the study. Median follow-up was 22.6 ± 16.7 months. Complete aneurysm thrombosis occurred in 92.9% of cases (23/25 cases) at 18 months. Freedom from sac enlargement was 100% (25/25 cases) with 17 cases of aneurysm sac shrinkage (68%). At 1, 6, 12 and 24 months, estimated primary patency was 95.7%, 87.3%, 77% and 70.1%, respectively. At the same intervals, primary-assisted patency was 95.7%, 91.3%, 86% and 86%, respectively, and secondary patency was 100%, 95.7%, 90.3% and 90.3%, respectively. Technical success was 100%. The collateral vessels patency was 72.4%. Limb salvage was 91.4% at 24-month follow-up. One multilayer flow modulator fracture was reported in an asymptomatic patient. Conclusions Multilayer flow modulator seems a feasible and safe solution for endovascular treatment of popliteal artery aneurysms in selected patients.

Descending thoracic aorta remodeling after multilayer stent release.

The multilayer flow modulator (MFM) is a device whose real effectiveness in the treatment of thoracoabdominal aortic aneurysms is not clear yet. A 68-year-old man with a 18-mm blister-like aneurysm of the descending thoracic aorta underwent endovascular exclusion, complicated by the thrombosis of a previous aortobi-iliac prosthesis, treated with embolectomy and femorofemoral bypass. Therefore, an MFM placement was planned. The postoperative course was uneventful and the 6-month computed tomography scan showed a complete thrombosis and remodeling of the aneurysm. The MFM stent could be an alternative treatment for saccular thoracic aortic aneurysm in high-risk patients but should not be used indiscriminately when other modalities of aortic repair are not feasible. Longer follow-up is mandatory to prove the efficacy of this technology.

History of the diagnosis and treatment of critical limb ischemia and diabetic foot.

The history of the recognition and surgical treatment of lower limb ischemia dates back to the Middle Ages. The twin Saints Comas and Damian were ascribed to have saved a gangrenous limb in the 13th century and became patrons of future surgeons. The physicians that followed developed the theories of blood flow, anatomy of the arterial circulation, and recognition that occlusive disease was the cause of limb ischemia and gangrene. Innovative physicians developed the techniques of arterial surgery and bypass grafting to restore limb blood flow and allow healing of lesions. In the 1960s, the era of endovascular intervention by the pioneering work of Charles Dotter, who developed techniques to image diseased arteries during a recanalization procedure. The development of guide wires, angioplasty balloons, and stents quickly followed. Management of lower limb ischemia and the diabetic foot will continue to evolve, building on the history and passion of preceding physicians and surgeons.

Effectiveness of 3D printed models in the treatment of complex aortic diseases.

BACKGROUND: The treatment of complex aortic diseases has known in the last years an extraordinary improvement, thanks to the development of new devices and techniques, especially concerning endovascular surgery. In this field, technological evolution has enabled vascular surgeons to overcome anatomical concerns and impairments that in the past made endovascular treatment unfeasible in many cases. However, the full exploitation of the devices offered by medical industry requires more and more powerful and accurate tools for case-by-case analysis and preoperative planning. Beside traditional imaging techniques, such as computed tomographic angiography (CTA), and virtual 3D reconstructions, an increasing interest towards 3D printing has been reported in the latest years. The purpose of this paper is to assess the actual value of this technology by reporting its use in 25 cases of complex aortic surgery. METHODS: For each patient, we have 3D printed a preoperative life-sized model of the vascular aortic lumen, deciding and planning the most suitable procedure by its direct examination. After the intervention, we have examined the corresponding model printed derived from postoperative CTA to check the outcome and discuss possible further corrections, if needed. RESULTS: All the cases for which a surgical or endovascular procedure was decided were treated successfully, in absence of major complications or intra-operative mortality. CONCLUSIONS: Optimal resolution of anatomical details and immediate comprehension of the most important technical aspects were reported by examining the models. 3D printing has proved a valuable tool in dealing with complex aortic diseases.

Endovascular Exclusion of Aortobronchial Fistula and Distal Anastomotic Aneurysm after Extra-Anatomic Bypass for Aortic Coarctation.

The treatment of choice for aortic coarctation in adults remains open surgical repair. Aortobronchial fistula is a rare but potentially fatal late sequela of surgical correction of isthmic aortic coarctation via the interposition of a graft. The endovascular treatment of aortobronchial fistula is still under discussion because of its high risk for infection, especially if the patient has a history of cardiovascular prosthetic implantation. Patients need close monitoring, most notably those with secondary aortobronchial fistula. We discuss the case of a 65-year-old man who presented with the combined conditions, and we briefly review the relevant medical literature.