A Systematic Review and Meta-Analysis of Carotid Artery Stenting for the Treatment of Cervical Carotid Artery Dissection.

OBJECTIVE: To assess the efficacy and safety of carotid artery stenting for the treatment of extracranial carotid artery dissection (CAD). DATA SOURCES: Systematic review using Medline, Scopus, EMBASE, and the Cochrane Library. REVIEW METHODS: A systematic search was performed according to the Preferred Reporting Items for Systematic reviews and Meta-analysis statement. Data from the eligible studies were extracted and meta-analysed. Primary endpoints included post-operative mortality, cerebrovascular events (CEs), and modified Rankin Score for neurological disability (mRS) at 90 days. Subgroup analyses were performed between stenting of spontaneous and traumatic CAD, primary stenting vs. stenting after failed medical therapy (FMT), and stenting of CAD in the presence of tandem occlusions vs. stenting of isolated extracranial CAD. RESULTS: Twenty-four studies with 1 224 patients were included. Pooled post-operative mortality, CE, and mRS 0 - 2 rates were 1.71% (95% confidence interval [CI] 0.83 - 2.80), 6.45% (95% CI 2.80 - 11.10), and 76.13% (95% CI 64.15 - 86.50), respectively. The pooled stroke rate was 2.16% (95% CI 0.0 - 6.64). Spontaneous vs. traumatic CAD mortality rates were 3.20% (95% CI 1.80 - 4.88) and 0.00% (95% CI 0.00 - 1.59) while CE rates were 14.26% (95% CI 6.28 - 24.36) and 1.64% (95% CI 0.0 - 6.08). Primary stenting and stenting after FMT mortality rates were 0.63% (95% CI 0.0 - 5.63) and 0.0% (95% CI 0.0 - 2.24), while CE rates were 5.02% (95% CI 0.38 - 12.63) and 3.33% (95% CI 0.12 - 9.03). Mortality rates for tandem occlusions and isolated extracranial CAD were 5.62% (95% CI 1.76 - 10.83) and 0.23% (95% CI 0.0 - 1.88), respectively, while CE rates were 15.28% (95% CI 6.23 - 26.64) and 1.88% (95% CI 0.23 - 4.51). The methodological index for non-randomised studies score was 8.66 (low). CONCLUSION: Both primary stenting and stenting of spontaneous CAD yielded unfavourable results with respect to stent thrombosis and stroke rates. Conversely, stenting following FMT had acceptable mortality and complication rates corroborating the use of stenting in the setting of CAD as a second line treatment. Due to the low quality of the included studies, definite conclusions cannot be drawn necessitating further research.

Use of the Off-The-Shelf Pre-Cannulated E-Nside Endograft to Overcome Anatomical Challenges in Urgent Complex Endovascular Aortic Repair.

Treatment options for large or symptomatic complex aortic aneurysms that require urgent intervention remain limited. Patient factors and comorbidities often make open surgery unappealing, leading to increasing interest in endovascular solutions that can be employed in the urgent setting, such as off-the-shelf endografts. The E-nsideTM (Jotec GmbH, Hechingen, Germany) is a new off-the-shelf endograft with 4 pre-cannulated inner branches that has recently become available in Europe. We report the urgent treatment of 2 large complex aortic aneurysms using this device and discuss the benefits of this new technology. The E-nside off-the-shelf endograft with inner branches is a useful addition to our treatment options for complex aortic aneurysms, particularly those with a narrow aortic lumen. Pre-cannulation of branches provides consistent access to the branches and a readily available option for establishment of a through and through wire for added stability during cannulation and bridging stent-grafts placement. The design of inner branches provides flexibility during deployment of the endograft and cannulation of the target vessels in varied, challenging anatomies.

Early outcomes of Jotec inner-branched endografts in complex endovascular aortic aneurysm repair.

OBJECTIVE: Complex aortic endografts have evolved to include inner branches to overcome specific challenges with existing technologies. We have reported the early outcomes of endovascular aortic aneurysm repair (EVAR) using a Jotec inner branched endograft (iBEVAR). METHODS: All patients who had undergone complex EVARs using extra-design engineering iBEVAR (Jotec GmbH, Hechingen, Germany) from 2018 to 2020 at a single center were reviewed. The patient demographics, cardiovascular risk factors, anatomic features of the aneurysms, and target vessels were recorded. The reasons for using inner branches instead of fenestrated and standard branched endografts and the procedural details, outcomes, and reintervention during follow-up were examined. RESULTS: A total of 110 patients were treated with branched and fenestrated endografts during the study period, of whom 18 patients had had a patient-specific custom-made iBEVAR endograft with downward inner branches. The technical success rate was 100%. A total of 68 target vessels were cannulated, and bridging stent-grafts were placed successfully in all. The reasons for choosing the iBEVAR design included unfavorable target vessel trajectory for fenestrated repair (n = 15), excessive infrarenal aortic angulation and/or adverse iliac access vessels for fenestrated repair (n = 11), the presence of a narrow aortic lumen (n = 14), and/or to reduce aortic coverage compared with that with standard outer branched repair (n = 14). We also used iBEVAR to treat type Ia endoleaks after failed EVAR with a short main body (n = 5). The median contrast volume used was 120 mL (range, 48-200 mL), with a median fluoroscopy screening time of 66 minutes (range, 35-136 minutes) and a median dose-area product of 17,832 dGy∙cm2 (range, 8260-55,070 dGycm2). No 30-day mortality and no major complications occurred. One early intervention was required for a suspected type Ib endoleak from an iliac limb and one late intervention for in-stent stenosis in a renal bridging stent-graft. One patient had died of non-aortic-related causes at 3 months. All other patients continued with follow-up with their aneurysms excluded, patent target vessels, and no type I or III endoleak identified at a median follow-up of 12 months (range, 1-26 months). CONCLUSIONS: The use of Jotec extra-design engineering endografts incorporating downward inner branches resulted in satisfactory early outcomes with a low reintervention rate. The technology has the potential to be a useful addition to our armamentarium for treating complex aortic endografts; however, long-term outcomes data are needed.

WILD Sheath Technique: "WIre Loop Directional" Sheath for Retrograde Femoral Access in Branched Endovascular Aortic Aneurysm Repair.

Branched endovascular aortic aneurysm repair (BEVAR) necessitates upper limb access (ULA) to facilitate the antegrade cannulation of downward directional branches and the placement of the bridging stent grafts. Various technical solutions to avoid ULA have been proposed and successfully applied in a limited number of cases. This can be necessary in specific clinical scenarios such as hostile aortic arch and descending thoracic aortic anatomy, or in the case of previous aortic arch and supra-aortic vessels surgery complicating the conventional approach with ULA in BEVAR. Taking inspiration from the prior description of a precursory technique, we report the application of our technique in BEVAR procedures, using standard introducer sheaths as a directional stable platform to facilitate an "All Femoral Access" (AFA) approach without the need for ULA, snaring or commercial steerable sheaths. Our concept is based on utilizing a wire loop to form a directional sheath (WILD sheath technique).

The efficacy of salvage interventions on threatened distal bypass grafts.

OBJECTIVE: Infrapopliteal bypass is an established and effective method for limb salvage in patients with critical limb ischemia. Secondary interventions maybe required to maintain graft patency. The aim of this study was to look at the frequency and outcomes of such interventions. METHODS: Consecutive patients undergoing bypasses onto the infrapopliteal vessels for critical limb ischemia (Rutherford 4-6) at a single institution were analyzed between 2009 and 2013. The primary end points were graft patency, amputation-free survival (AFS), and freedom from reintervention at 12 months by Kaplan-Meier analysis. RESULTS: A total of 114 infrapopliteal bypasses were performed in 102 patients. Distal anastomosis was on to the anterior tibial (n = 31), posterior tibial (n = 27), peroneal (n = 24), tibioperoneal trunk (n = 23), or dorsalis pedis artery (n = 9). Primary patency, assisted primary patency, and secondary patency was 57%, 76%, and 82%, respectively, at 12 months and 44%, 70%, and 80%, respectively, at 36 months. AFS was 80% at 12 months and 65% at 36 months. Endovascular salvage interventions were performed on 58 grafts (51%) including angioplasty of inflow/proximal anastomosis (33%), outflow/distal anastomosis (46%), and graft stenosis (20%), with a further 12 grafts (11%) undergoing thrombolysis for occlusion. Surgical salvage interventions included jump grafts (n = 7), revision of anastomotic stenosis (n = 3), and thrombectomy (n = 2). AFS was similar in salvaged threatened and acutely occluded grafts compared with nonthreatened grafts (P = .064) and better in grafts requiring reintervention later (>6 months from bypass) compared with those requiring early reintervention (<6 months; P = .047). CONCLUSIONS: Secondary interventions in threatened distal bypass grafts are successful at maintaining graft patency and AFS when compared with nonthreatened grafts, and are associated with a low morbidity rate.

Laparoscopic Management of Concomitant Sigmoid Colon Cancer and Type 2 Endoleak Following Endovascular Aneurysm Repair.

The co-occurrence of abdominal aortic aneurysm (AAA) and colorectal malignancy creates a significant surgical dilemma over which entity should be addressed first. A 73-year-old male was referred to our hospital due to a painful pulsatile abdominal mass. Computed tomographic angiography revealed an infrarenal aortic aneurysm measuring 5.8 cm in diameter and incidentally, a synchronous mass lesion in the sigmoid colon. The patient underwent an emergency EVAR using a Gore Excluder endograft. Postoperative CT staging for colon cancer revealed a type 2 endoleak on the grounds of a patent wide inferior mesenteric artery. The patient underwent a standard laparoscopic left colectomy with high ligation of the inferior mesenteric artery in order to simultaneously address the ongoing type 2 endoleak. Follow-up examinations with computed tomographic angiography were performed confirming the resolution of the endoleak. Synchronous laparoscopic sigmoidectomy and high ligation of inferior mesenteric artery for type 2 endoleak treatment appears to be applicable with hopeful results.

Venous Thromboprophylaxis With Neuromuscular Stimulation: Is It Calf Muscle Pumping or Just Twitches and Jerks?

The common peroneal nerve stimulator (CPNS) is a UK-approved device for reducing venous thromboembolism risk. It resembles a wrist watch and is placed over the common peroneal nerve to fire at 1 electrical impulse/sec. The aim was to quantify the claim that it drives the venous muscle pump and imitates walking. Twelve healthy volunteers performed 10 tip-toe maneuvers and 10 ankle dorsiflexions to imitate walking movements. The reductions in calf volume were recorded using air plethysmography (APG). The common peroneal nerve was stimulated for over 10 seconds at each of the 7 increasing electrical impulse settings, and the volume reductions were measured for comparison. The results are expressed as median (interquartile range) absolute (mL), and percentage reduction in calf volume. Tip-toe and dorsiflexion pumping maneuvers were not significantly different: 59 (33.6-96.1), 81.9% vs 51.4 (34-68.5), 59.7%, respectively ( P = .53). However, they both outperformed the CPNS: 10.8 (7.3-18), 13.2% at P = .002 and P = .002, respectively. Qualitatively, the CPNS registered on the tracings as a small spike (muscle twitch) at low settings, with larger amplitudes (ankle jerk) at higher settings. The CPNS activity spikes were discrete, lasting a median (range) of 0.24 (0.16- .3) seconds. The claim that the CPNS empties veins by pumping is supported statistically. However, the amount is small versus the tip-toe and dorsiflexion maneuvers. Furthermore, the CPNS has a short activity profile on the APG trace. Innovations that produce sustained contraction and involve the posterior calf compartments may improve pumping.

Usefulness of new imaging methods for assessment of type B aortic dissection.

While the medical management of uncomplicated type B aortic dissection has good outcomes in the short term, the longer term mortality can be in the region of 50% at 5 years. Up to 40% of the survivors can have significant dilatation of the false lumen with the risk of aneurysm formation and death due to rupture. The results of the randomized controlled trials ADSORB and INSTEAD-XL have shown that beneficial aortic remodelling occurs after endoluminal stent graft placement, but these trials were underpowered to show any effect on survival. Static computed tomography (CT) angiography imaging methods have been used to try to identify high risk patients using parameters such as diameter, the position and size of the entry tear, and the amount of false lumen thrombus, but these so far are not able to clinically risk stratify individual patients. In this manuscript, we present our initial experience with new MR imaging methods. These have allowed us to develop a greater understanding of aortic dissection by providing information regarding the underlying hemodynamic and biomechanics of the dissection, as well as more accurate assessment of important clinical imaging endpoints, such as false lumen thrombosis.