Endovascular Treatment of an Internal Iliac Artery Aneurysm in a Patient with Previous Aortic Surgery Using a Novel Covered Stent Graft.

BACKGROUND: We report endovascular treatment of a patient with an isolated Internal Iliac Artery (IIA) aneurysm who was treated by positioning a novel covered stent that could adapt to different proximal and distal diameters. CASE REPORT: A 68-year-old man who had already had several previous aortic surgeries underwent endovascular treatment for a 41 mm isolated right IIA aneurysm. Two Viabahn VBX (W. L. Gore & Associates, Flagstaff, AZ) covered stents (7 × 79 mm and 8Lx59 mm) were placed from a 6 mm gluteal artery to an 11 mm Dacron hypogastric artery via contralateral femoral surgical access. No complications occurred. One-month follow-up computed tomography angiography (CTA) scan showed the complete exclusion of the aneurysmal sac with spontaneous endoleak resolution and patency of the covered stents. Geometric analysis of the postoperative CTA highlighted VBX conformability to the native vessel. Maximum stented vessel diameter ranged between 9 and 13 mm, and circularity was maintained along the whole stent length, even in zones of higher centerline curvature. CONCLUSIONS: The Viabahn VBX covered stent could be used to treat aneurysms of the IIA.

Geometrical Evaluation of Aortic Sac Remodeling During Two-Step Thoracoabdominal Aortic Aneurysm Endovascular Repair.

BACKGROUND: The present study evaluates aneurysmal sac remodeling and the loss of the intercostal arteries after the first step of staged treatment of thoracoabdominal aortic aneurysms (TAAAs). The purpose of this approach is to keep the aneurysmal sac temporarily perfused to induce progressive thrombosis of the aneurysm while simultaneously allowing the spinal cord to establish adequate perfusion thereby promoting the development of collateral circulation. METHODS: All patients with type II or type III TAAAs, having undergone 2-step endovascular treatment with at least a 2-branch endoprosthesis at our institution between April 2017 and May 2019, were retrospectively evaluated. Thirty-day mortality and spinal cord ischemia was assessed. The mean number of the intercostal and lumbar arteries, coverage length between the left subclavian artery and the stent graft proximal landing zone, total volume of the aneurysmal sac, lumen volume, and thrombosis volume were measured by preoperative and first-step postoperative computed tomography angiography. Patients were also grouped based on the chosen endoprosthesis (group A: double-branch aneurysmal sac reperfusion; group B: single-branch aneurysmal sac reperfusion). RESULTS: Eleven patients (mean age: 76.5 years; range: 61-86) were considered. No 30-day mortality was observed after the first-step procedure, and 1 patient died after second-step treatment. No permanent paraplegia was observed after either the first or second endovascular steps. The lumen volume significantly decreased (27%; P < 0.001) after first-step endovascular treatment although there was a significant increase in aneurysm thrombosis (34% to 54%). The mean number of the intercostal arteries decreased from 19.7 to 9.3 (P < 0.001) after first-step endovascular treatment. Volume variations and percentage of intercostal loss did not significantly differ between the 2 groups. CONCLUSIONS: Although aneurysm volume continued to increase after first-step treatment, two-step endovascular treatment is a feasible alternative to reduce the risk of severe ischemia in patients with extended TAAAs.

In Vivo Morphological Changes of the Femoropopliteal Arteries due to Knee Flexion After Endovascular Treatment of Popliteal Aneurysm.

Purpose: To evaluate morphological changes of the femoropopliteal (FP) arteries due to limb flexion in patients undergoing endovascular treatment of popliteal artery aneurysms (PAAs). Materials and Methods: Seven male patients (mean age 68 years) underwent endovascular treatment of PAA with a Viabahn stent-graft between January 2013 and December 2017. During follow-up, one contrast-enhanced computed tomography angiography (CTA) scan of the lower limbs was acquired for each recruited patient. A standardized CTA protocol for acquisitions in both straight-leg and bent-leg positions was used to visualize changes in artery shape due to limb flexion. Three-dimensional reconstruction of the FP segment was performed to compute mean diameter and eccentricity of the vascular lumen and to measure length, tortuosity, and curvature of the vessel centerline in 3 arterial zones: (A) between the origin of the superficial femoral artery and the proximal end of the stent-graft, (B) within the stent-graft, and (C) from the distal end of the stent-graft to the origin of the anterior tibial artery. Results: After limb flexion, all zones of the FP segment foreshortened: 6% in zone A (p=0.001), 4% in zone B (p=0.001), and 8% in zone C (p=0.07), which was the shortest (mean 4.5±3.6 cm compared with 23.8±5.7 cm in zone A and 23.6±7.4 cm in zone B). Tortuosity increased in zone A (mean 0.03 to 0.05, p=0.03), in zone B (0.06 to 0.15, p=0.005), and in zone C (0.027 to 0.031, p=0.1). Mean curvature increased 15% (p=0.05) in zone A, 27% (p=0.005) in zone B, and 95% (p=0.06) in zone C. In all zones, the mean artery diameter and eccentricity were not significantly affected by limb flexion. Conclusion: Limb flexion induces vessel foreshortening and increases mean curvature and tortuosity of the FP segment both within and outside the area of the stent-graft.

Kidney Preservation Using Renal Heterotopic Autotransplantation during Fenestrated Endovascular Aortic Repair for Complex Residual Type-A Aortic Dissection.

The treatment of type A acute aortic dissection is a challenge for the surgeon, and serious late complications may occur even after surgical repair. We report treatment after a type A postdissection thoracoabdominal aneurysm in a patient who previously underwent ascending aortic reconstruction using a biological aortic valve and Dacron prosthetic graft implantation in emergency conditions. The multistaged approach involved removing the right kidney and performing a heterotopic autotransplantation in the left iliac fossa before positioning a fenestrated endograft (celiac trunk, superior mesenteric artery, and left renal artery). The final step should have been the implantation of an aorto-bifurcated endograft, which, however, was postponed because the patient was injured during rehabilitation therapy. After 12 months, the computed tomography angiography scan showed complete thrombosis of the false lumen associated with large iliac entry tear closure and aortic diameter stability. These findings prompted us to desist from completing the aorto-bi-iliac implantation. This case demonstrates that in selected patients in whom treatment of a postdissection thoracoabdominal aneurysm with fenestrated endoprosthesis requires a challenging revascularization of the renal artery, a heterotopic kidney transplant using a mini-invasive technique may represent a viable and sufficiently safe alternative that guarantees renal blood perfusion.

Twelve-year Follow-up Post-Thoracic Endovascular Repair in Type B Aortic Dissection Shown by Three-dimensional Printing.

BACKGROUND: Thoracic endovascular repair (TEVAR) is currently considered the therapy of choice for complicated type B acute aortic dissection (TBAAD). Although several papers have reported good outcomes at short- and medium-term follow-up, some questions still remain regarding the long-term durability and re-intervention rate during follow-up. METHODS: We describe a case of a patient originally treated with TEVAR for TBAAD complicated by impending aortic rupture. RESULTS: Endovascular repair successfully excluded the flow through the primary entry tear but during the 12-year follow-up period the patient experienced several complications and re-interventions. Various full-size three-dimensional (3D) models of the patient-specific vasculature were printed to better explain the different interventional interventions over the 12 years of follow-up and as a hands-on tool for medical education. CONCLUSIONS: The present case report, involving long-term follow-up, provides an example of the effectiveness and the safety of TEVAR for the treatment of complicated TBAAD shown at short and medium-term follow-up. However, the long-term complications that were observed in this patient during follow-up support the importance of lifelong CTA surveillance. Furthermore, this study confirms the capability of 3D printing technology as a powerful tool to support communication with patients and residents' education through the physical analysis of the real cases.

Geometric Analysis of Complex Endovascular Treatment of a Successfully Completed Residual Post-Type A Aortic Dissection.

We describe a case of complex multistep endovascular treatment of a post-Type A thoracoabdominal dissected aneurysm. Volume analysis documents true and false lumen improvements during follow-up. Centerline tortuosity of the aorta and of the iliac arteries straightens after endovascular treatment completion. In addition, analysis of stent-graft remodeling reveals the stent-graft tendency to spring back to its original status together with a caudal migration of the fenestrated body.

Geometric Analysis to Determine Kinking and Shortening of Bridging Stents After Branched Endovascular Aortic Repair.

PURPOSE: To evaluate bridging stent geometry in patients who underwent branched endovascular aortic repair (B-EVAR) and to correlate the outcomes with intrinsic bridging stent characteristics aiming to identify the stent(s) that guarantees the best performance. METHODS: Pre-operative and post-operative computed tomography images of all patients undergoing B-EVAR between September 2016 and April 2019 were retrospectively analyzed. Following geometrical features were measured: target vessel take-off angle (TOA); longitudinal stent shortening; shape index (SI), intended as ratio between minimum and maximum diameter of the lumen cross sections, averaged on three segments: zone 1 (proximal stented zone), zone 2 (intermediate), and zone 3 (distal). RESULTS: Thirty-eight branches (8 right (RRA) and 8 left renal arteries (LRA), 11 superior mesenteric arteries (SMA), 11 celiac trunks (CTR)) were treated. Fluency (Bard Peripheral Vascular), COVERA (Bard Peripheral Vascular), and VBX (WLGore&Assoc) stent-grafts were implanted in 10, 12, and 16 branches, respectively. Pre-operative TOA was more acute in RRA and LRA when compared to CTR and SMA, and straightened in post-operative configuration (109.86 ± 28.65° to 150.27 ± 21.0°; P < 0.001). Comparable values of SI among the stent types were found in zone 1 (P = 0.08), whereas higher SI in VBX group was detected in zones 2 (P < 0.001) and 3 (P < 0.001). The VBX group was also the most affected by stent shortening (11.12 ± 5.65%; P = 0.001). CONCLUSION: Our early experience showed that the VBX stent offers greater stent circularity than the other devices even if a greater shortening has been observed drawing attention with regards to the decision of the nominal stent length.

Role of interactive home telemedicine for early and protected discharge 1 day after carotid endarterectomy.

Our aim was to prove the feasibility and safety of a protocol for early and protected discharge 1 day after carotid endarterectomy (CEA) using a system of telemedicine (TMD) monitoring. Among 147 patients operated upon for 163 CEAs, we selected a group (A) of 36 patients fulfilling criteria for discharge 1 day after surgery. An electronic blood pressure manometer, a videophone, an antihypertensive drug (amlodipine), and a customer satisfaction questionnaire were given to every group A patient. With a video-communication program linked to the Web, we monitored every 4 hours (from 8:00 a.m. to 8:00 p.m.) for 2 days the surgical wound, blood pressure, and heart frequency of the patients. Other patients were included in group B. No differences regarding demographic characteristics, risk factors, carotid lesions, operative time, postoperative complications, or blood loss were noted between group A and group B. Twenty-one patients in group A were actually discharged 1 day after surgery. No cervical hematoma developed. Three hypertensive crises were treated successfully in group A. From the questionnaire a feeling of insecurity at discharge emerged, but it rapidly resolved. The overall cost of video connections was 25.39 +/- 0.25 Euros per patient. CEA can be safely done as 1-day surgery using a TMD monitoring system in selected cases. Our protocol allowed early discharge safely, leading to reduced hospital costs.

[Penetrating aortic ulcer: a series of 15 cases with thoracic and thoraco-abdominal management]. / UIcère pénétrant de l'aorte: a propos de quinze cas traités aux niveaux thoracique et thoraco-abdominal.

Penetrating aortic ulcer (PAU) consists of an ulcer located in the aortic wall that can cause sudden-onset thoracic or thoraco-abdominal pain. Symptomatic PAU is a life-threatening emergency because of the high risk of aortic rupture. First described in 1934, PAU was for many years seen only at autopsy. Now, multislice CT is the diagnostic method of choice. We report the cases of 15 such patients. Ten patients were symptomatic, with severe sudden-onset thoracic or thoraco-abdominal pain (7 cases) or less acute pain (3 cases). Surgical treatment consisted of aortic stent-grafting in 13 cases, with one or more endoprostheses. Bypass surgery was also necessary in 6 cases, using a hybrid technique (ilio-hepatic bypass graft in 1 case, multiple visceral bypass grafts in 3 cases, carotid-carotid bypass graft in 1 case, and carotid left subclavian bypass graft in 1 case), or a combined technique (aneurysmectomy and infrarenal Dacron tube repair in 1 case). Open thoraco-abdominal aortic repair was performed in two cases, with proximal anastomosis at the thoracoabdominal level and distal anastomosis at the level of the aortic carre four (with the Crawford inclusion technique in one case). Perioperative results were satisfactory, but one patient died of multiple organ failure on postoperative day 14. Four patients died during follow-up (mean 16.2 months ; range 1-44 months), 1 of stroke, 1 of a complicated esophageal-aortic fistula, and 2 of unknown causes. Follow-up has been uneventful in the other 10 patients.

Early evaluation of precise deployment with the new low-profile Zenith Alpha Thoracic Endoprosthesis in thoracic aortic disease.

BACKGROUND: Endovascular treatment of thoracic aortic disease currently allows to treat high-risk patients with better results than open repair. It represents the first option for treatment according to the most recent guidelines. The aim of the study is to evaluate the early results of the low-profile Zenith Alpha Thoracic Endoprosthesis (ZATE). METHODS: Between October 2012 and July 2015, 14 asymptomatic patients were treated with ZATE. 10 patients were male, mean age was 71, 7 years (range 58-85 years). 8 patients presented with atherosclerotic aortic aneurysm (7 thoracic aneurysm and 1 type I thoracoabdominal aneurysm), 2 chronic type B aortic dissection, 1 type IV endoleak 5 years after TEVAR, 3 aortic arch penetrating ulcers complicated by pseudoaneurysm. Hybrid staged procedures in 11 patients included 7 total aortic arch debranching (1 single [innominate] chimney stent-graft + carotid-carotid-subclavian), 2 carotid-carotid-subclavian artery bypass, 2 carotid-subclavian artery bypass. RESULTS: No 30-day mortality or major complications were observed. The mean length of stay was 7.3 days (range 4-14 days). Mean procedure time, X ray time and Contrast load were 115 minutes (range 90-150 minutes), 20 minutes (range 10-30) and 79 mL (range 40-120 mL) respectively. 25 stent-grafts were implanted. The mean follow-up was 21 months (range 14-32 months). No mortality and no major complications were observed during the follow-up. In case of arch debranching with landing 0 and 1 zone the mean distance between the beginning of the endoprosthesis and the debranching inflow vessel was 5.5±2.4 mm. CONCLUSIONS: The use of ZATE could be a viable alternative for treating patients with aortic arch proximal landing zone to facilitate the precise deployment. Larger case studies and longer follow-up are needed.

What is the Best Revascularization Strategy for Acute Occlusive Arterial Mesenteric Ischemia: Systematic Review and Meta-analysis.

PURPOSE: Acute mesenteric ischemia (AMI) is a life-threatening disease that leads to bowel infarction and death. The optimal management of AMI remains controversial. The present meta-analysis aimed to estimate the prognostic impact of surgical (SG) versus endovascular or hybrid intervention (EV) as the first-line treatment for acute arterial occlusive mesenteric ischemia and to assess whether endovascular strategy was actually effective in reducing bowel resection. METHODS: MEDLINE, Scopus and the Cochrane Library databases were searched. There have been no randomized controlled trials comparing SG versus EV for the treatment of AMI. We undertook this systematic review and meta-analysis according to MOOSE (Meta-analysis of Observational Studies in Epidemiology) guidelines, assessing the included study quality with the Newcastle-Ottawa scale. RESULTS: Seven studies comparing EV versus SG as first strategy for the treatment of AMI were selected for the analyses, reporting of 3020 patients. EV was associated with a reduced risk of in-hospital mortality (RR 0.68; 95% CI 0.59-0.79; fixed-effects analysis; p < 0.0001; I 2 = 4.9%; τ 2 = 0.025). Pooled prevalence of mortality was 19% for EV and 34% for SG. EV also showed a benefit impact on risk of bowel resection and second-look laparotomy. CONCLUSIONS: The present meta-analysis outlines that endovascular revascularization strategy seems to offer advantages in terms of in-hospital mortality and morbidity in case of arterial occlusive AMI. A multidisciplinary team consisting of radiologists, interventional radiologists, cardiovascular and general surgeons comes out to be essential to tailor the right procedure to the patient and improve the outcomes associated with AMI.

Effects of Pleiotrophin on endothelial and inflammatory cells: Pro-angiogenic and anti-inflammatory properties and potential role for vascular bio-prosthesis endothelialization.

PURPOSE: One of the limitations emerged with both synthetic and degradable vascular grafts is the lack of endothelialization after implantation that is known to be the main reason leading to unfavourable outcomes. It emerges the need to find new strategies to promote a rapid endothelialization of the scaffold. Pleiotrophin is a growth/differentiation cytokine for various cell type. We here evaluated the effect of Pleiotrophin on endothelial cells (EC), monocytes and macrophages that have been shown as key cells promoting neovascularization. MATERIAL/METHODS: EA.hy926 endothelial cells, THP-1 monocytes and PMA-differentiated macrophages were treated with Pleiotrophin (10 and 100ng/ml). VEGF, Flk-1, Nrp-1, COX-2, ICAM-1 and TGFß expression were detected by Western Blot, IL-10, MCP-1 and TNFα levels by ELISA. Chemotaxis was performed in Boyden chambers. Wound healing was performed by scratch wound assay. RESULTS: Pleiotrophin induces in EC the expression of VEGF and its receptors Flk-1 and Nrp-1 and improves the migratory capacity. In THP-1 monocytes, Pleiotrophin induces the expression of VEGF and its receptor Nrp-1 and decreases the levels of COX-2 and TNFα. In PMA-differentiated macrophages COX-2 expression was significantly reduced by Pleiotrophin, while IL-10 and TGFß were increased. CONCLUSIONS: Pleiotrophin acts as an angiogenesis 'driver' by promoting the creation of a pro-angiogenic environment, a migratory behaviour in EC and a pro-regenerative alternative phenotype in macrophages. Our results suggest that Pleiotrophin might be considered for vascular prosthesis engineering.