Off-the-Shelf Strategy for Endovascular Aneurysm Repair of Ectopic, Dominant, Renal Artery Originating From the Aortic Bifurcation: Case Report.

INTRODUCTION: An ectopic renal artery originating from the aortic bifurcation can strongly interfere with surgical or endovascular intervention in the infrarenal aorta. CASE: We present an infrarenal symptomatic aneurysm with a right ectopic/pelvic kidney associated with 1 renal artery originating from the aortic bifurcation. RESULT: During an endovascular aortic repair (EVAR) procedure, the dominant ectopic right kidney was perfused by an iliac branch device (IBD) used as an iliac extension. However, out of instructions for use (IFU), this is an "off-the-shelf" resolution for this type of rare case. CONCLUSION: The use of an "off-the-shelf" IBD to perform an EVAR with an ectopic renal artery, in patients unfit for open surgery, is a potentially valuable option.

Efficacy and Safety of Percutaneous Access Via Large-Bore Sheaths (22-26F Diameter) in Endovascular Therapy.

PURPOSE: To evaluate the closure success rate's outcomes with suture-mediated vascular closure device Perclose ProGlide in patients undergoing aortic or iliac artery endovascular repair using large delivery systems (>21F). MATERIALS AND METHODS: We screened all the patient records in aortic databases at 2 centers who had undergone vascular interventions via ProGlide for percutaneous femoral access >21F between 2016 and 2020. Patients were divided into 2 groups according to the delivery system size: large (L) (22F-23F) and extra-large (XL) (24F-26F). Demographics, anatomical details, and outcome of percutaneous access were evaluated. RESULTS: Included were 239 patients: 121 in the L group and 118 the XL group. Intraprocedural conversion to open surgery because of bleeding was necessary in 2% L and 6% XL patients (p=0.253). Severe femoral artery calcification was the sole risk factor for converting to open surgery (odds ratio=23.44, 95% confidence interval=1.49-368.17, p=0.025). In all, 2% of L and 3% of XL (p=0.631) did require late percutaneous intervention due to stenosis (all treated with balloon angioplasty). Overall, 3% developed pseudoaneurysm treated conservatively in all except one patient requiring surgical repair. Hematoma and groin infection were observed in 9% and 1%, respectively; none required surgical therapy. CONCLUSION: A femoral arterial defect after accessing the artery via a large bore sheath (22F-26F) can be closed successfully with ProGlide in more than 90% of patients. Severe femoral artery calcification is a risk factor for conversion to open surgery caused by bleeding. CLINICAL IMPACT: This study adds evidence on efficacy of accessing the artery via a large bore sheath (22-26F) secured by ProGlide. In more than 200 patients conversion to open surgery was necessary in only 4%. Severe femoral artery calcification was the sole risk factor for converting to open surgery. Our findings encourage physicians to choose the percutaneous access even in patients requiring the use of large bore sheath.

Ultrasound-Guided Pectoserratus Plane Block and Superficial Serratus Anterior Plane Block for Subcutaneous Implantable Cardioverter-Defibrillator Implantation: A Comparative Study.

BACKGROUND The combination of pectoserratus plane block (PSP) and superficial serratus anterior plane block (S-SAP) was established to reduce the risk of general anesthesia for subcutaneous implantable cardioverter-defibrillator (S-ICD) implantation in patients with high operative risk (American Society of Anesthesiologistsgrade III or IV). This study compared outcomes from ultrasound-guided PSP and S-SAP in 16 patients requiring a subcutaneous implantable cardioverter-defibrillator (S-ICD) at a single center in Poland. MATERIAL AND METHODS A group of 16 patients with ASA grade III and IV qualified for S-ICD implantation was included. The pain assessment using numerical rating scale (NRS), patient's comfort using Quality of Recovery-15 (QoR-15), the operator's satisfaction using Operator's Comfort Scale, adverse event occurrence, and the parameters' stability were evaluated. RESULTS The mean volume of the local anesthetics mixture of PSP block was 19.4 mL; S-SAP was 34.7 mL (mean total volume, 54.1 mL). The mean duration of the block was 21.3 min; the mean time of the S-ICD implantation was 108.4 min. Neither circulatory nor respiratory instability was observed. In 8 patients (50%), non-opioid analgesics were administered intraoperatively; in 11 patients (69%), fentanyl bolus ≤200 µg was administered. The intraoperative NRS score was low (max 2 points); NRS 24 h after the procedure was low (max 4 points). The mean value of QoR-15 was 133.9 points. CONCLUSIONS S-SAP combined with PSP is feasible and safe in providing anesthesia/analgesia during S-ICD implantation and showed good effects in a group of patients with high operative risk (ASA III or IV).

Rotational Atherectomy Plus Drug-Coated Balloon Angioplasty for the Treatment of Total In-Stent Occlusions in Iliac and Infrainguinal Arteries.

PURPOSE: To analyze the long-term outcomes of a hybrid treatment method combining rotational atherectomy with drug-coated balloon (DCB) angioplasty in patients with total in-stent occlusion in the iliac and/or infrainguinal arteries. MATERIALS AND METHODS: Between April 2014 and June 2017, 74 consecutive patients (mean age 66.7±9.7 years; 49 men) with total occlusion of a previously implanted stent underwent endovascular recanalization using the Rotarex system and DCB angioplasty. Half (37, 50%) of the patients had critical limb ischemia (CLI), and 30 (41%) of the procedures were performed in emergency. Mean lesion length was 22±15 cm. RESULTS: Overall procedure success was achieved in 73 (98.6%) patients. Six (8.1%) CLI patients developed distal embolism that responded to thrombolysis. Three (4.1%) dissections did not require treatment, while 1 (1.4%) perforation necessitated stent-graft implantation. In all, 33 (44.6%) patients had an additional stent implanted, mainly due to a suboptimal outcome (n=28) or complications (n=5 including the stent-graft). The restenosis rate assessed by duplex ultrasound at 12 months was 20.5% (15/73); 4 (5.5%) patients underwent target lesion revascularization. Recurrent restenosis was more frequent in patients with Rutherford category 5 ischemia (p=0.005), in emergency procedures (p=0.021), after extensive procedures involving 3 independent vessel segments (p=0.016), and if a complication arose during the procedure (p<0.001). In multivariate analysis, only occurrence of a procedural complication was an independent predictor of recurrent restenosis at 1 year (OR 63.3, 95% CI 5.7 to 701.5). CONCLUSION: These findings imply that rotational atherectomy and DCB angioplasty may provide satisfactory outcomes in the treatment of total in-stent occlusion, with a satisfactory recurrent restenosis rate at 12 months.

Use of vascular closure devices for endovascular interventions requiring a direct puncture of PETE grafts.

BACKGROUND: Effectiveness of vascular closure devices during endovascular procedures requiring a direct puncture of a vascular prosthesis placed in the inguinal region is unknown. PATIENTS AND METHODS: The retrospective analysis included 134 patients with a history of polyethylene terephthalate (PETE) graft implantation in the inguinal region. In 20 (15 %) patients, haemostasis was achieved with manual compression, in 21 (16 %) with the StarClose™, and in 93 (69 %) with the AngioSeal™ device. RESULTS: The incidence of vascular complications in the manual compression group was higher (at a threshold of statistical significance) than in the device closure group (45.0 vs. 24.5 %, p = 0.059). The difference was considered statistically significant when manual compression was compared with the AngioSeal™ closure group (45.0 vs. 13.9 %, p < 0.01). The vascular complication rate in the StarClose™ group was significantly higher than in the AngioSeal™ group (71.4 vs. 13.9 %, p < 0.000001). While haematomas were the only vascular complications observed after application of AngioSeal™, both haematomas and pseudoaneurysms were found in the StarClose™ group. CONCLUSIONS: The AngioSeal™ vascular closure device provides better local haemostasis than the StarClose™ device or manual compression during endovascular interventions requiring a direct puncture of PETE grafts.

Role of vascular endothelial growth factor in inducing production of angiopoetin-1 - in vivo study in Fisher rats.

The aim of the study was to investigate how an intramuscular injection of plasmids with genes coding various pro-angiogenic factors: angiopoetin-1 (ANGPT1), vascular endothelial growth factor (VEGF165) and hepatic growth factor (HGF), influences the production of ANGPT1. 40 Healthy Fisher rats received i.m. injections containing plasmids encoding pro-angiogenic genes in thigh muscles. They were divided into four equal groups. The first group received the plANGPT1 plasmid and the second group- the pIRES/ANGPT1/VEGF165 bicistronic plasmid. The pIRES/VEGF165/HGF bicistronic plasmid was administered to the third group and an empty plasmid (control group) to the fourth group. The animals were euthanized after 12 weeks. In each group, the number of vessels stained with the anti-ANGPT1 antibody was assessed under an optical microscope. The anti-ANGPT1 antibodies stained the vessels in all the groups. There were on average 14.1 ±2.3 vessels in the the plANGPT1 group, 32.5 ±10.5 in the pl/RESANGPT1/VEGF group and 30.8 ±13.3 in the plRES/HGV/VEGF group. There were on average 7.3 ±2.3 stained vessels (p < 0.0001) in the control group . The VEGF plays a role in the induction of the production of ANGPT1. The administration of plasmids only encoding ANGPT1 does not induce its production.

A middle mesenteric artery.

In 114 cases of the transverse colon isolated from cadavers (50 male, 64 female), anatomical examinations of the arterial system of the colon were performed. Arteriograms were obtained after dissecting and contrasting the colonic vessels with Mixobar contrast. In one case, on arteriography of the colon with its mesentery isolated from a 55-year-old male cadaver, a rare anatomical variant was found. The third mesenteric artery originated directly from the aorta-halfway between the superior and inferior mesenteric arteries and ascended obliquely in the direction of the hepatic flexure of the colon. Supply area of the artery was typical for the middle colic branch of the superior mesenteric artery: the distal segment of the ascending colon and the transverse colon. Such a variation, although very rare, may have particular impact on diagnosis and even the method and range of surgery.

[Modern treatment of rupturted abdominal aortic aneurysms with the use of synthetic endovascular prostheses]. / Leczenie peknietych tetniaków aorty brzusznej z uzyciem syntetycznych protez wewnatrznaczyniowych.

AIM OF STUDY: We analyzed the case of two patients with ruptured aortic aneurysm treated with the usage of the endowascular method. MATERIALS AND METHODS: Treatment of ruptured abdominal aortic aneurysms is burdened with a high mortality rate during the perioperative period. The implantation of forked stent-grafts and uni-grafts significantly reduced the mortality rate in this group of patients. Usage of this treatment requires the hybrid operating room. An essential element is to have the appropriate amount of equipment available to find a suitable intravascular prostheses. Uni-grafts are a good alternative for smaller divisions and for physicians with less experience in endovascular surgery. CONCLUSION: Endowascular procedures have a great chance to became a golden treatment standard.

[Usage of hydrophilic catheters and guidewires in endovascular surgery]. / Zastosowanie prowadników i cewników hydrofilnych w chirurgii endowaskularnej.

AIM OF STUDY: The aim of this study was to evaluate the effectiveness of hydrophilic catheters and guidewires during endovascular overcoming long stenoses or occlusions of the superficial femoral and popliteal artery. MATERIAL AND METHODS: Based on 142 procedures rated the functionality of the equipment of the hydrophilic coating. The operations were performed in the years 2010-2012 in the Department of Vascular, General and Transplantation, Medical University in Wroclaw. Procedures related to recanalization or enlargement of the superficial femoral artery. Patients were divided into groups according to the Consensus TASC II depending on the length change. Each patient was assessed ankle-brachial ratio (ABI), claudication distance measured and constructed with double ultrasound imaging (USG-DD). In doubtful cases an additional study was performed with contrast computed tomography (angio-CT). The procedure was performed at the Laboratory of angiography using a angiograph Siemens Artis Zee Ceiling. Every time the contrlateral access was made, and as the first step the angiography was performed to verify type of changes in the arteries RESULTS: . A significant benefit of using hydrophilic guidewires and catheters in patients with long stenoses or occlusions. In case of long and calcified changes, hydrophilic catheters was the only option because it gave good support for hydrophilic guidewire. CONCLUSIONS: The changes in the type C and D according to the criteria for TASC II, an essential tool to achieve a positive treatment effect is the use of hydrophilic catheters and guidewires.

[The treatment of aorto-duodenal fistula with the use of the endovascular prosthesis]. / Zaopatrzenie przetoki aortalno-dwunastniczej z uzyciem protezy wewnatrznaczyniowej--opis przypadku.

One of the most common and serious complications after implantation of aortic or aorto-femoral prosthesis are aortoduodenal fistula. Secondary aorto-duodenal fistula is the most commonly observed form of a fistula between the abdominal aorta and gastrointestinal tract. 76 years old male with infected vascular prosthesis was admitted to Clinic with syndroms of active bleeding from aorto-duodenal fistula. Because of general condition, patient was qualified to endovascular procedure, and a new stentgraft was implanted. After the procedure patient was treated with antibiotic compatible with inoculation from blood and he did not gave agreement for further surgical operations. He lived next 28 months and died because of lung cancer.

[The treatment of dissected thoraco-abdominal aorta aneurysm with the use hybrid procedure]. / Zaopatrzenie tetniaka aorty piersiowo-brzusznej przy uzyciu procedur hybrydowych.

AIM OF STUDY: We analyzed the case of a patient treated in Vascular Surgery Department with the use of the hybrid procedure with a good results. MATERIALS AND METHODS: Acute cases of dissected aortic aneurysm are commonly known as an immediate danger of human live and determinate a big challenge for physicians. The collaboration of classic and endovascular methods (hybrid procedures) gives much more chances to improve patient's survival and resumption to normal life activity. Endovascular procedures are limiting the operation shock, improving recovery time. That means rising the chances of survival so advanced surgical procedure. CONCLUSION: Hybrid procedures are a modern technic that gives good results.

Modified implantation of a Bolton Relay branch arch device into the ascending aorta close to a mechanical aortic valve.

An aortic arch stent graft is usually contraindicated with a mechanical aortic valve. However, a modified stent graft plus the use of an externalized transapical guidewire technique allowed a safe implantation close to a mechanical aortic valve.

Pressure gradient measurement to verify hemodynamic results of the chimney endovascular aortic repair (chEVAR) technique.

PURPOSE: The use of the pressure gradient measurements to assess the renal artery flow hemodynamics after chimney endovascular aortic repair (chEVAR). METHODS: The study was a prospective analysis of 37 chEVAR procedures performend in 24 patients with perirenal aortic aneurysm. In all patients the measurement of: distal renal artery pressure (Pd), aortic pressure (Pa), Pd/Pa ratio (Pd/Pa) and mean gradient (MG) between the aorta and the distal renal artery were performed. Measurements were taken with 0.014 inch pressure wire catheter before and after the chEVAR procedure. MG greater than 9 mmHg and Pd/Pa ratio below 0.90 were considered as the measures of a significant decrease in distal pressure that limited flow in renal arteries. The 6 month follow-up computed tomographic angiography (CTA) was performed in all patients to diagnose potential endoleak presence and to verify the patency of the chimney stent-grafts. RESULTS: All procedures were successful, and no periprocedural complications were observed in any of the patients. The mean gradient values before and after the chimney implantation did not change significantly (6,2±2,0 mmHg and 6,8±2,2 mmHg, respectively). Similarly, no significant change in Pd/Pa values was noted with the value of 0.9 observed both before and after the procedure. All chimney stents were patent on the control CTA. Type Ia endoleak was found in 4 (10.8%) patients. CONCLUSIONS: The application of the described technique seems to be a safe method which allows a direct measurement of renal artery flow hemodynamics before and after chimney implantation during the chEVAR technique. The use of covered balloon expandable stents, ensures the proper blood flow in the renal arteries during the chEVAR technique.

Evaluation of the Effectiveness of Modified Pectoral Nerve Blocks Type II (PECS II) for Vascular Access Port Implantation Using Cephalic Vein Venesection.

The vascular access port implantation procedure can be performed using the venesection method by inserting a catheter into the cephalic vein in the region of the deltopectoral groove. This method eliminates the need for catheter tunneling. An alternative method to infiltration anaesthesia for port implantation may be a modified pectoral nerve block type II (PECS II). This study aimed to evaluate the effectiveness of modified PECS II for vascular access port implantation using cephalic vein venesection. This retrospective observational study was conducted at the 4th Military Clinical Hospital in Wroclaw, Poland. A group of 114 patients underwent the modified PECS II block and additional cutaneous infiltration anesthesia at the incision line. Pain intensity was assessed on the NRS scale measured intraoperatively at four points. The QoR-15 questionnaire was used to assess patient satisfaction during the first 24 h after surgery. The operator's condition assessment score was used to assess surgical conditions and operator comfort. The analysis showed that the median pain intensity during vascular port implantation was 0. A statistically significant difference in pain intensity was demonstrated between the specialist's group and the resident's group at the second and third measurement points (p < 0.008; p < 0.012). The mean value on the QoR-15 scale was 132. There was a significant difference between the pain scores of the groups. The mean score in the pain position in the specialist's group was 18 points and in the resident's group, it was 19 points (p < 0.029). In conclusion, the present study revealed that the modified PECS II block is an effective and safe method of anesthesia for Port-A-Cath implantation.

Immunohistochemical localization of interleukin-6 in human pancreatitis.

The aim of the study was to identify immunohistochemically the localization of interleukin (IL)-6 in normal pancreas and in chronic pancreatitis (CP). Samples of tissues of normal pancreas (n=5) and CP (n=16), were verified histopathologically and then IL-6 was localized by immunohistochemical staining using the monoclonal antihuman IL-6 antibody and test LSAB2-HRP to visualize IL-6/Ab complexes. In slices of the pancreas, derived from patients with CP, a much stronger immunohistochemical reaction was noticed as compared with controls specimens. IL-6 was localized in exocrine, islet cells and ducts cells of the pancreas. Interestingly, this cytokine was detected in cytoplasm and very close to nucleus. Moreover, in cases of CP with inflammatory infiltration, there were a markedly stronger IL-6 expression, than that observed in specimens without infiltrate. In conclusion, the results presented herein clearly demonstrated a moderate and strong expression of IL-6 in exocrine and endocrine cells of patients with CP. These observations provide further support for the existence of local immune-pancreatic interactions.

[Incidence of factor VII and C3 in vascular anastomosis]. / Wystepowanie czynnika VII krzepniecia krwi oraz czynnika C3 ukladu dopelniacza w zespoleniach naczyniowych.

In order to study pathogenesis of vascular prosthesis healing process the following experiment was designed. 16 dogs underwent implantation of unilateral straight aorto-femoral teflon (PTFE, polytetrafluoroethylene) by-pass. After 6 months all dogs were killed, dissected and vascular prostheses with margin of adjacent aorta and femoral artery were collected for further study. Areas of proximal and distal anastomosis were examined immunohistochemically. Presence of coagulation factor VII, and C3 complement factor were studied. The obtained results were analyzed statistically by means of t-Student test. Factor VII as well C3 were found in areas of both proximal and distal anastomosis. Concentration of all two substances in proximal and distal anastomosis was compared. No statistically valid differences in factor VII concentration in proximal and distal anastomosis were found, whereas amounts of C3 factor as well as degree of extracellular matrix infiltration were markedly higher in distal anastomosis.