Saphenous vein ablation with a new cyanoacrylate glue device: a systematic review on 1000 cases.

BACKGROUND: To review published evidence regarding an n-butyl-cyanoacrylate (NBCA) injection device for great (GSV) and small (SSV) saphenous vein incompetence in terms of occlusion rate, postoperative complications and quality of life improvement. MATERIAL AND METHODS: International bibliographic databases (PubMed, EMBASE, Scopus) were searched to identify possible target articles. The only inclusion criterion was the use of the Variclose® system (Biolas, Ankara, Turkey) for superficial vein insufficiency. Exclusion criteria were case reports, review, meta-analysis, article with <6-month follow-up data, abstracts and congress presentations. PRISMA guidelines were used to lead articles selection. RESULTS: Seven studies were included in the final data analysis. A total of 918 patients (1000 limbs) underwent an NBCA procedure for GSV (947 cases) or SSV (53 cases) incompetence. The average procedure duration was 11.7 min. The most common postoperative complications were postoperative pain (4.8%) and superficial vein thrombosis (2.1%). No deep vein thrombosis or pulmonary embolism cases were described. The occlusion rates at six, 12 and 30 months were 97.3%, 96.8% and 94.1%, respectively. CONCLUSION: NBCA injection with the Variclose device seems to be a feasible, effective and safe treatment in GSV incompetence. Long-term follow-up studies and randomized controlled trials are needed to achieve high-quality evidence.

Endovascular Treatment of Popliteal Artery Aneurysms: A Word of Caution after Long-Term Follow-up.

BACKGROUND: The aim of this work was to evaluate the long-term patency of endografting in the treatment of popliteal artery aneurysms (PAAs) and to identify which factors may be predictors of graft occlusion. METHODS: All the patients who underwent endovascular repair of PAA were analyzed from 2006 until 2014 on the basis of symptoms, comorbidities, limb salvage, and long-term patency. The predictive value of the different variables was assessed in univariate analysis for primary patency and, for factors resulted significant, a multivariate analysis was performed. The Kaplan-Meier life table method was used to calculate patency and limb salvage. RESULTS: We treated 65 PAAs in 57 patients (53 men and 4 women). PAAs were symptomatic in 26 cases (40%) and 34% were the emergency cases; the mean aneurysm size was 33.8 ± 17 mm. Mean follow-up was 35 months ± 25. Graft occlusion occurred in 22 limbs (35%). We had 9 amputations (14.5%). The late conversion to open surgery was 6.4%. The cumulative estimated 60-month primary patency, secondary patency, and limb salvage were respectively 57% (standard error [SE] ±0.7), 73% (SE ±0.7), and 83% (SE ±0.5). We found that diabetes (hazard ratio [HR] 2.936, 95% confidence interval [CI] 0.993-8.683), associated percutaneous transluminal angioplasty (PTA) procedures (HR 2.534, 95% CI 1.115-5.757), symptoms (HR 2.492, 95% CI 1.127-5.510), and runoff scores (HR 2.069, 95% CI 0.942-4.544) were the most important risk factors for long-term patency at univariate analysis. When considering a multivariate analysis symptoms (HR 2.066, 95% CI 0.862-4.952) become the principal risk factor followed by diabetes (HR 1.808, 95% CI 0.531-6.157)], runoff scores (HR 1.716, 95% CI 0.757-3.893) and associated PTA procedures (HR 1.441, 95% CI 0.519-3.839), but no one reached a statistical significance. CONCLUSIONS: On the base of our experience it seems that several factors affect durability in PAA endovascular repair, especially the presence of acute symptoms, diabetes, and runoff. Therefore until further refined clinical studies, we believe that the actual role of this technique must be yet clarified.

Relationship between great saphenous vein recanalization, venous symptoms reappearance, and varicose veins recurrence rates after endovenous radiofrequency ablation.

The term "recurrence" in chronic venous disease remains not yet well defined, despite numerous reports describing patterns and causes of the presence of recurrent varicose veins (RVVs). Moreover, saphenous trunk recanalization (STR) has also been documented as one of the major source of RVVs and it is widely used to indicate the "failure" of endovenous ablation. Finally, reappearance of venous symptoms (VSym) should be considered to reach a complete "recurrence" evaluation. RVVs, STR, and VSym rates and mutual co-presence after endovenous treatments are still unclear. The aim of this report is to describe and analyze these three recurrence components after 6 years in patients underwent radiofrequency ablation of the great saphenous vein.

Ten years of endovascular aortic arch repair.

PURPOSE: To evaluate a 10-year single-center experience of arch endovascular aortic repair (AEVAR) using the hybrid approach. METHODS: Between 1999 and 2009, 311 patients were treated with endografts for thoracic aortic pathologies. The aortic arch was involved in 116 (37.3%) patients (97 men; mean age 70.3+/-10.7 years, range 27-84). There were 83 atherosclerotic aneurysms, 21 type B dissections, and 12 other lesions whose proximal landing zones were categorized according to Ishimaru's classification as 24 zone 0, 27 zone 1, and 65 zone 2. A hybrid approach was performed for all zone 0 and zone 1 procedures and in nearly half (47.7%) of zone 2 procedures. Early and midterm outcomes were reviewed retrospectively. RESULTS: The initial clinical success in zone 0 aneurysms was 83.3%, with a 30-day mortality of 12.5% due to intraoperative stroke in all the cases. The respiratory failure rate was 12.5%, and there was 1 type I endoleak that spontaneously resolved at follow-up. Midterm clinical success at a mean 26+/-21 months was 83.3%. In zone 1 aneurysms, the initial clinical success was 82.1% without 30-day mortality or perioperative stroke. The midterm clinical success was 81.5% at a mean 21+/-17 months [2 (7.4%) late aneurysm-related deaths]. Four type I endoleaks spontaneously resolved in 3 patients. In zone 2 cases, the initial clinical success was 90.8%. There was 1 (1.5%) intraoperative death and another (1.5%) within 30 days; 1 (1.5%) patient suffered a stroke, and the respiratory and renal failure rates were 3.0%, respectively. This is the only zone in which paraplegia (2 patients, 3.0%) was encountered. The midterm clinical success was 93.9% at a mean 34+/-20 months. Four type I endoleaks spontaneously resolved in 3 patients at follow-up. CONCLUSION: In selected patients, early and midterm outcomes of AEVAR using the hybrid approach are promising; however, mortality and morbidity, especially for zones 0 and 1, are not negligible. Our results may have practical implications for the ongoing evolution of the hybrid procedure in the aortic arch, as well as for patients fit for traditional surgery.

Distal embolization and proximal stent-graft deployment: a dual approach to endovascular treatment of ruptured superior gluteal artery aneurysm.

Aneurysmal disease of the hypogastric branches is rare; it may be life-threatening, and the treatment is often challenging. Herein, we report the case of an 81-year-old man with arterial hypertension, obesity, renal insufficiency, and psychiatric disorders who was emergently admitted for a symptomatic ruptured aneurysm of a hypogastric arterial branch, as seen on magnetic resonance angiography. Endovascular treatment was performed by means of a dual approach: distal embolization with microspheres and Gianturco coils, followed by proximal complete exclusion via deployment of a stent-graft in the common iliac artery. The outcome was favorable, with complete exclusion of the aneurysm and normalization of renal function. Endovascular treatment with distal embolization and proximal stent-graft release can be safe and effective, and the technique can be used in emergency circumstances with good morphologic and clinical results.

Aorto-iliac aneurysm associated with congenital pelvic kidney: a short series of successful open repairs under hypothermic selective renal perfusion.

The occurrence of congenital pelvic kidney (cPK) during aorto-iliac aneurysm repair is an extremely unusual finding. We report a series of four patients with aorto-iliac aneurysm and associated cPK who underwent aorto-iliac repair at our institution over the last 10 years. Aorto-iliac aneurysm repair under cPK selective hypothermic perfusion was successfully accomplished in all cases. All the cPK arteries were spared and were selectively reimplanted when required. No major complications or death were reported at long-term follow-up. Open surgical repair of aorto-iliac aneurysm in patients with cPK is safe and effective and, in our short series, we observed no worsening of the renal function; besides, we reported a persistent improvement of the renal function in two out of the four cases.

Evaluation of a new disease-specific endovascular device for type B aortic dissection.

OBJECTIVE: The study objective was to evaluate the feasibility, safety, and early technical and clinical success rate of a new endovascular device specifically designed for aortic dissection that has recently become available in Europe. METHODS: From June of 2005 to the present, the Zenith Dissection Endovascular System (William Cook Europe, Bjaerverskov, Denmark) was used in 11 selected patients (all male, with a median age of 58 years [range, 45-76 years]) with type B chronic aortic dissection with a compression or collapse of the true lumen. All procedures were performed under general anesthesia with preoperative cerebrospinal fluid drainage in 4 patients. One-step open surgical supra-aortic vessels re-routing was performed in 6 patients to obtain an adequate proximal landing zone: Left carotid-subclavian artery bypass was performed in 5 patients, and right-to-left common carotid artery bypass and left subclavian to common carotid artery transposition was performed in 1 patient. Clinical follow-up visits and computed tomography scans were obtained at 1, 6, and 12 months, and yearly thereafter. RESULTS: A secondary technical success was obtained in all patients (100%), and 30-day clinical success was achieved in 10 patients (91%). A type IA entry flow was observed in 1 patient. No mortality was recorded. Occlusion of visceral/renal arteries, retrograde dissections, and device-induced tears in the intimal lamellae were not observed. Periprocedural morbidity included temporary renal failure in 1 patient and postimplantation syndrome with fever and leukocytosis for 23 days in 1 patient. No cases of paraplegia were recorded. At a median follow-up of 12 months (range, 2-30 months), we observed a clinical success rate of 91%. No migration of the device was observed. No late occlusion of the visceral or renal arteries was recorded at follow-up. CONCLUSION: The perioperative and short-term follow-up results showed that the Zenith Dissection Endovascular System for the treatment of aortic dissection can be safely used without affecting the patency of the branches covered by the bare stent. However, these results need to be validated in a larger group of patients with a mid-term follow-up.

Hybrid repair of an aortic arch aneurysm with complex anatomy: right aortic arch and anomalous origin of supra-aortic vessels.

We performed a one-stage hybrid surgical and endovascular procedure to manage a 6.5-cm right aortic arch aneurysm associated with anomalous origin of the supra-aortic vessels in a 70-year-old man. Complete surgical rerouting of the supra-aortic vessels was followed by the endovascular repair of the right aortic arch aneurysm with a Zenith TX2 stent graft (Cook, Bloomington, Ind) and Z-track plus introducer system. The procedure was successfully completed with exclusion of the aortic arch aneurysm, and the patient was discharged on postoperative day 7. Aortic arch aneurysms with complex anatomy may be successfully treated with a less invasive hybrid approach using new generation devices.

Hybrid approach to thoracoabdominal aortic aneurysms in patients with prior aortic surgery.

OBJECTIVE: The hybrid approach to the repair of thoracoabdominal aortic aneurysm (TAAA), consisting of visceral aortic debranching with retrograde revascularization of the splanchnic and renal arteries and aneurysm exclusion using stent grafts, has been previously described and may be considered particularly appealing in high-risk patients, especially those who have undergone prior aortic surgery. This study analyzed prospectively recorded data of a series of high-risk patients with prior aortic surgery who underwent hybrid TAAA repair at our institute and contrasted the outcomes with those of a similar group of patients who underwent conventional open TAAA repair. METHODS: Between 2001 and 2006, 13 patients (12 men) with a median age of 69.6 years (range, 35 to 82 years) underwent one-stage hybrid repair of TAAA (7 type I, 2 type II, 2 type IV, and 2 aneurysms of the visceral aortic patch). These patients, the hybrid group, had a history of aortic surgery (30.7% ascending, 30.7% descending, 46.1% abdominal aortic repair, and 15.4% redo TAAA) and were at high risk for open repair. The criteria used to define these patients as high risk and to indicate the need for hybrid treatment were American Society of Anesthesiologists (ASA) class 3 or 4 associated with a preoperative forced expiratory volume in 1 second (FEV1)<50%. In all cases, we accomplished partial or total visceral aortic debranching through (1) a previous visceral artery retrograde revascularization with synthetic grafts (single bypass, customized Y or bifurcated grafts), and (2) aortic endovascular repair with one of three different commercially produced stent grafts (Cook, W.L. Gore & Assoc, and Medtronic). We analyzed the results and compared the outcomes of the hybrid group with those of a similar group of 29 patients (25 men) with a median age 65.3 years (range, 58 to 79) selected from our overall series of 246 TAAA repairs between 1988 and 2005. These 29 patients, the conventionally treated group, were selected for having had aortic surgery (22% ascending, 38% descending, 42% abdominal aortic repair, and 10.3% redo TAAA), an ASA 3 or 4, a preoperative FEV1<50%, and a conventional open repair of TAAA (10 type I, 5 type II, 4 type III, 7 type IV, and 3 aneurysms of the visceral aortic patch). RESULTS: In the hybrid group, 32 visceral bypasses were completed and endovascular TAAA repair was successful in all cases. No intraoperative deaths occurred. Perioperative mortality was 23%, and morbidity was 30.8% (renal failure in 2, respiratory failure in 1, and delayed transient paraplegia in 1). At a median follow-up of 14.9 months (range, 11 days to 59.4 months), all grafts were patent at postoperative computed tomography angiography and no aneurysm-related deaths, endoleak, stent graft migration, or morbidity related to visceral revascularization had occurred. No conventionally treated patients died intraoperatively. Perioperative mortality was 17.2% and morbidity was 44.8% (respiratory failure in 7, coagulopathy in 1, renal failure in 2, and paraplegia in 3). At a median follow-up of 5.4 years (range, 1.7 to 7.9 years), no significant complications related to aortic repair occurred, except for three patients (10.3%) with asymptomatic dilatation of the visceral aortic patch<5 cm undergoing radiologic surveillance. CONCLUSION: Hybrid TAAA repair is technically feasible in selected cases. Perioperative morbidity and mortality were considerable in our subset of high-risk patients with prior aortic surgery, but no aneurysm-related or procedure-related complications were reported at mid-term follow-up. Hybrid TAAA repair did not lead to a significant improvement in outcomes compared with open TAAA repair in a similar group of patients. Larger series are required for valid statistical comparisons and longer follow-ups are necessary to evaluate the durability of hybrid repairs.

Endovascular treatment of aortic arch aneurysms / Tratamento endovascular dos aneurismas de arco aórtico

BACKGROUND: Endovascular approach to the aortic arch is an appealing solution for selected patients. OBJECTIVE: To compare the technical and clinical success recorded in the different anatomical settings of endografting for aortic arch disease. METHODS: Between June 1999 and October 2006, among 178 patients treated at our institution for thoracic aorta disease with a stent-graft, the aortic arch was involved in 64 cases. According to the classification proposed by Ishimaru, aortic zone 0 was involved in 14 cases, zone 1 in 12 cases and zone 2 in 38 cases. A hybrid surgical procedure of supra-aortic debranching and revascularization was performed in 37 cases. RESULTS: Zone 0. Proximal neck length: 44±6 mm. Initial clinical success was 78.6 percent: two deaths (stroke), one type Ia endoleak. At a mean follow-up of 16.4±11 months the midterm clinical success was 85.7 percent. Zone 1. Proximal neck length: 28±5 mm. Initial clinical success was 66.7 percent: 0 deaths, four type Ia endoleaks. At a mean follow-up of 16.9±17.2 months the midterm clinical success was 75.0 percent. Zone 2. Proximal neck length: 30±5 mm. Initial clinical success was 84.2 percent: two deaths (one cardiac arrest, one multiorgan embolization), three type Ia endoleaks, one case of open conversion. Two cases of delayed transitory paraparesis/paraplegia were observed. At a mean follow-up of 28.0±17.2 months the midterm clinical success was 89.5 percent. CONCLUSIONS: This study and a literature review demonstrated that hybrid procedure for aortic arch pathology is feasible in selected patients at high risk for conventional surgery. Our experience is still limited by the relatively small sample size. We propose to reserve zone 1 for patients unfit for sternotomy or in cases with aortic neck length > 30 mm following left common carotid artery debranching. We recommend to perform complete aortic rerouting of the aortic arch in cases with lesser comorbidities and shorter aortic neck.

CONTEXTO: O tratamento endovascular dos aneurismas do arco aórtico é uma solução interessante para pacientes selecionados. OBJETIVO: Comparar os sucessos técnico e clínico registrados nas diferentes regiões anatômicas do arco aórtico após a colocação de endoprótese. MÉTODOS: Entre junho de 1999 e outubro de 2006, 178 pacientes foram tratados na nossa instituição devido a doenças da aorta torácica com a colocação de endoprótese, sendo que o arco aórtico estava envolvido em 64 casos. De acordo com a classificação proposta por Ishimaru, a zona aórtica 0 estava envolvida em 14 casos, zona 1 em 12 casos e zona 2 em 38 casos. Procedimentos de debranching do arco aórtico e revascularização extra-anatômica dos troncos supra-aórticos foram realizados em 37 casos para obter um adequado colo aórtico proximal. RESULTADOS: Zona 0. Comprimento do colo proximal: 44±6 mm. Sucesso clínico inicial de 78,6 por cento: dois óbitos (acidente vascular cerebral), um vazamento do tipo Ia. Seguimento médio de 16,4±11 meses com sucesso clínico a médio prazo de 85,7 por cento. Zona 1. Comprimento do colo proximal: 28±5 mm. Sucesso clínico inicial de 66,7 por cento: 0 óbitos, quatro vazamentos do tipo Ia. Seguimento médio de 16,9±17,2 meses com sucesso clínico a médio prazo de 75 por cento. Zona 2. Comprimento do colo proximal: 30±5 mm. Sucesso clínico inicial de 84,2 por cento: dois óbitos (um infarto cardíaco e uma embolização de múltiplos órgãos), três vazamentos do tipo Ia, um caso de conversão para operação aberta. Dois casos de paraparesia/paraplegia transitória tardia foram observados. Seguimento médio de 28,0±17,2 meses com sucesso clínico a médio prazo de 89,5 por cento. CONCLUSÃO: Este estudo e a análise da literatura demonstram que o procedimento híbrido para moléstia do arco aórtico é factível em pacientes selecionados com alto risco para a operação convencional. Nossa experiência ainda é limitada pelo tamanho relativamente pequeno da amostra. Sugerimos...