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OBJECTIVE: The aim of this multicenter national study was to compare the outcomes of primary open surgery by aorto-bifemoral bypass (ABFB) with those performed after a failed endovascular treatment (EVT) by kissing stent technique for complex aortoiliac occlusive disease (AIOD) lesions (TransAtlantic Inter-Society Consensus [TASC] II C and D). METHODS: All consecutive ABFB cases carried out at 12 vascular surgery centers between 2016 and 2021 were retrospectively collected and analyzed. Data included patients' baseline demographics and clinical characteristics, procedural details, perioperative outcomes, and follow-up results (survival, patency, amputation). The study cohort was divided into two groups based on indications for ABFB: primary treatment vs secondary treatment after EVT failure. RESULTS: Overall, 329 patients underwent ABFB during the study period (71% males; mean age, 64 years), of which 285 were primary treatment and 44 were after prior EVT. At baseline, no significant differences were found between study groups in demographics and clinical characteristics. TASC C and D lesions were similarly represented in the study groups (TASC C: 22% vs 78%; TASC D: 16% vs 84%). No major differences were found between study groups in terms of procedural details, early mortality, and perioperative complications. At 5 years, primary patency rates were significantly higher for primary ABFB (88%; 95% confidence interval [CI], 93.2%-84%) as compared with ABFB after prior EVT (69%; 95% CI 84.9%-55%; log rank P value < .001); however, the 5-year rates of secondary patency (100% vs 95%; 95% CI, 100%-86%) and limb salvage (97%; 95% CI, 99%-96 vs 97%; 95% CI, 100%-94%) were similar between study groups. CONCLUSIONS: Surgical treatment of TASC C/D AIOD with ABFB seems to be equally safe and effective when performed after prior EVT, although primary ABFB seemed to have higher primary patency rates. Despite the need for more frequent reinterventions, secondary patency and limb salvage rates were similar. However, future large prospective trials are required to confirm these findings.
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Doenças da Aorta , Procedimentos Endovasculares , Artéria Ilíaca , Stents , Grau de Desobstrução Vascular , Humanos , Masculino , Feminino , Estudos Retrospectivos , Pessoa de Meia-Idade , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/instrumentação , Procedimentos Endovasculares/métodos , Idoso , Artéria Ilíaca/fisiopatologia , Artéria Ilíaca/cirurgia , Artéria Ilíaca/diagnóstico por imagem , Doenças da Aorta/cirurgia , Doenças da Aorta/diagnóstico por imagem , Doenças da Aorta/fisiopatologia , Doenças da Aorta/mortalidade , Fatores de Tempo , Artéria Femoral/fisiopatologia , Artéria Femoral/cirurgia , Artéria Femoral/diagnóstico por imagem , Fatores de Risco , Doença Arterial Periférica/fisiopatologia , Doença Arterial Periférica/diagnóstico por imagem , Doença Arterial Periférica/cirurgia , Doença Arterial Periférica/terapia , Salvamento de Membro , Resultado do Tratamento , Implante de Prótese Vascular/efeitos adversos , Implante de Prótese Vascular/instrumentação , Amputação CirúrgicaRESUMO
BACKGROUND: To describe the outcomes of aortic endograft thrombosis (AET) as an indication for open conversion (OC) after endovascular aortic aneurysm repair (EVAR) in a multicenter experience. METHODS: This study retrospectively analyzed cases of OC for AET following EVAR across 12 Italian Vascular Surgery centers from 1997 to September 2022. The end points were as follows: 30-day mortality and major postoperative complications. Follow-up data included survival and aortic-related complications. RESULTS: Sixteen patients (mean age: 68.6 ± 8.5 years) were included. The median elapsed time between EVAR and OC was 26.46 months (interquartile range: 13.8-45.9). Proximal aortic cross-clamping site was supraceliac in 8 out of 16 (50%) patients, and complete removal of the stentgraft was achieved in 75% of cases (12/16 patients). Reconstructions were aorto-bi-iliac grafts in 8 cases (50%), 7 aortobifemoral bypass grafts (43.8%), and 1 aortoaortic tube graft (6.3%). All patients were symptomatic at presentation (68.7% unilateral acute limb ischemia, 25% bilateral acute limb ischemia, 1 patient had chronic severe claudication). Thirty-day mortality was 12.5% (2/16 patients). The overall morbidity rate was 43.8% (7 of 16 patients). No specific risk factors for early mortality were found. The overall estimated survival rate was 80.4% at 1 year, 62.5% at 2 years, and 41.7% at 3 years. CONCLUSIONS: OC for AET is typically reserved for complex cases that are not amenable to endovascular solutions. The frequent need for suprarenal clamping and complete endograft removal seems to be associated with high short-term mortality.
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OBJECTIVE: To report on the recommendations of an expert-based consensus on the indications, timing, and techniques of aortic balloon occlusion (ABO) in the management of ruptured abdominal aortic aneurysms (rAAA). METHODS: Eleven facilitators created appropriate statements regarding the study issues that were voted on using a 4-point Likert scale with open-comment fields, by a selected panel of international experts (vascular surgeons and interventional radiologists) using a 3-round modified Delphi consensus procedure (study period: January-April 2023). Based on the experts' responses, only the statements reaching grade A (full agreement ≥75%) or B (overall agreement ≥80% and full disagreement <5%) were included in the final study report. The consistency of each round's answers was also graded using Cohen's kappa, the intraclass correlation coefficient, and, in case of double resubmission, Fleiss kappa. RESULTS: Sixty-three experts were included in the final analysis and voted on 25 statements related to indication and timing (n=6), and techniques (n=19) of ABO in the setting of rAAA. Femoral sheath or ABO should be preferably placed in the operating room, via a percutaneous transfemoral access, on a stiff wire (grade B, consistency I), ABO placement should be suprarenal and last less than 30 minutes (grade B, consistency II), postoperative peripheral vascular status (grade A, consistency II) and laboratory testing every 6 to 12 hours (grade B, consistency) should be assessed to detect complications. Formal training for ABO should be implemented (grade B, consistency I). Most of the statements in this international expert-based Delphi consensus study might guide current choices for indications, timing, and techniques of ABO in the management of rAAA. Clinical practice guidelines should incorporate dedicated statements that can guide clinicians in decision-making. CONCLUSIONS: At arrival and during both open or endovascular procedures for rAAA, selective use of intra-aortic balloon occlusion is recommended, and it should be performed preferably by the treating physician in aortic pathology. CLINICAL IMPACT: This is the first consensus study of international vascular experts aimed at defining the indications, timing, and techniques of optimal use of ABO in the clinical setting of rAAA. Aortic occlusion by endovascular means (or ABO) is a quick procedure in properly trained hands that may play an important role as a temporizing measure until the definitive aortic repair is achieved, whether by endovascular or open means. Since data on its use in hemodynamically unstable patients are limited in the literature, owing to practical challenges in the performance of well-conducted prospective studies, understanding real-world use by experts is of importance in addressing critical issues and identifying main gaps in knowledge.
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OBJECTIVE: The aim of this study is to compare early and follow-up outcomes of late open conversions (LOC, with complete or partial endograft explantation) and semi-conversions (SC, with endograft preservation) after endovascular aneurysm repair in a multicenter experience. METHODS: All LOC and SC performed from 1997 to 2020 in 11 vascular centers were compared. Endograft infections or thrombosis were excluded. Primary endpoints were early mortality and long-term survival estimates. Secondary endpoints were differences in postoperative complication rates and conversion-related complications during follow-up. RESULTS: In the considered period, 347 patients underwent surgery for endovascular aneurysm repair complications. Among these, 270 were operated on for endoleaks (222 LOC, 48 SC). The two groups were homogeneous in terms of American Society of Anesthesiologists score (LOC, 3.2 ± 0.7; SC, 3 ± 0.5; P = .128) and main endograft characteristics (suprarenal fixation, bifurcated/aorto-uni-iliac configuration). The mean age was 75 ± 8 years for LOC and 79 ± 7 years for SC (P = .009). Reasons for LOC were: 62.2% (138/222) type I endoleak, 21.6% (48/222) type II endoleak, 7.7% (17/222) type III endoleak, and 8.5% (19/222) endotension. Indications for SC were: 64.6% (31/48) type II endoleak, 33.3% (16/48) type I endoleak, and 2.1% (1/48) type III endoleak. Thirty-day mortality was 12.2% (27/222) in the LOC group, and 10.4% (5/48) in the SC group (P = .73). Postoperative complication rate was higher in the LOC group (45.5% vs 29.2%; P = .04). The estimated survival rate after LOC was 80% at 1 year and 64% at 5 years; after SC, it was 72% at 1 year and 37% at 5 years (log-rank P = .01). During the median follow-up of 21.5 months (interquartile range, 2.4-61 months), an endoleak after SC was found in the 38.3% of the cases; sac growth was recorded in the 27.7% of SC patients. CONCLUSIONS: SC has an early benefit over LOC in terms of reduced postoperative complications but has a significantly inferior mid-term survival. The high rates of persistent and/or recurrent endoleaks reduce SC durability.
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Aneurisma da Aorta Abdominal , Implante de Prótese Vascular , Procedimentos Endovasculares , Idoso , Idoso de 80 Anos ou mais , Aneurisma da Aorta Abdominal/complicações , Aneurisma da Aorta Abdominal/diagnóstico por imagem , Aneurisma da Aorta Abdominal/cirurgia , Implante de Prótese Vascular/efeitos adversos , Endoleak/diagnóstico por imagem , Endoleak/etiologia , Endoleak/cirurgia , Procedimentos Endovasculares/efeitos adversos , Humanos , Complicações Pós-Operatórias , Reoperação/efeitos adversos , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo , Resultado do TratamentoRESUMO
BACKGROUND: Surgical management of coexisting cardiac disease and extra-cranial carotid artery disease is a controversial area of debate. Thus, in this challenging scenario, risk stratification may play a key role in surgical decision making. AIM: To report the results of single-stage coronary/valve surgery (CVS) and carotid endarterectomy (CEA), and to identify predictive factors associated with 30-day mortality. METHODS: This was a multicenter, retrospective study of prospectively maintained data from three academic tertiary referral hospitals. For this study, only patients treated with single-stage CVS, meaning coronary artery bypass surgery or valve surgery, and CEA between March 1, 2000 and March 30, 2020, were included. Primary outcome measure of interest was 30-day mortality. Secondary outcomes were neurologic events rate, and a composite endpoint of postoperative stroke/death rate. RESULTS: During the study period, there were 386 patients who underwent the following procedures: CEA with isolated coronary artery bypass graft in 243 (63%) cases, with isolated valve surgery in 40 (10.4%), and combination of coronary artery bypass grafting and valve surgery in 103 (26.7%). Postoperative neurologic event rate was 2.6% (n = 10) which includes 5 (1.3%) transient ischemic attacks and 5 (1.3%) strokes (major n = 3, minor n = 2). The 30-day mortality rate was 3.9% (n = 15). Predictors of 30-day mortality included preoperative left heart insufficiency (odds ratio [OR]: 5.44, 95% confidence interval [CI]: 1.63-18.17, p = .006), and postoperative stroke (OR: 197.11, 95% CI: 18.28-2124.93, p < .001). No predictor for postoperative stroke and for composite endpoint was identified. CONCLUSIONS: Considering that postoperative stroke rate and mortality was acceptably low, single-stage approach is an effective option in such selected high-risk patients.
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Estenose das Carótidas , Doença da Artéria Coronariana , Endarterectomia das Carótidas , Acidente Vascular Cerebral , Humanos , Endarterectomia das Carótidas/métodos , Estudos Retrospectivos , Estenose das Carótidas/complicações , Doença da Artéria Coronariana/complicações , Acidente Vascular Cerebral/epidemiologia , Acidente Vascular Cerebral/etiologia , Fatores de Risco , Resultado do Tratamento , Complicações Pós-Operatórias/etiologiaRESUMO
OBJECTIVE: The characteristics and outcomes of patients undergoing vascular surgery hospitalised and managed in Lombardy are described with a comparison of patients tested positive for COVID-19 (CV19-pos) vs. those tested negative (CV19-neg). METHODS: This was a multicentre, retrospective, observational cohort study which involved all vascular surgery services in Lombardy, Northern Italy. Data were retrospectively merged into a combined dataset covering the nine weeks of the Italian COVID-19 pandemic phase 1 (8 March 2020 to 3 May 2020). The primary outcome was freedom from in hospital death, secondary outcomes were re-thrombosis rate after peripheral revascularisation, and freedom from post-operative complication. RESULTS: Among 674 patients managed during the outbreak, 659 (97.8%) were included in the final analysis: 121 (18.4%) were CV19-pos. CV19-pos status was associated with a higher rate of complications (OR 4.5; p < .001, 95% CI 2.64 - 7.84), and a higher rate of re-thrombosis after peripheral arterial revascularisation (OR 2.2; p = .004, 95% CI 1.29 - 3.88). In hospital mortality was higher in CV19-pos patients (24.8% vs. 5.6%; OR 5.4, p < .001;95% CI 2.86 - 8.92). Binary logistic regression analysis identified CV19-pos status (OR 7.6; p < .001, 95% CI 3.75 - 15.28) and age > 80 years (OR 3.2; p = .001, 95% CI 1.61 - 6.57) to be predictors of in hospital death. CONCLUSION: In this experience of the vascular surgery group of Lombardy, COVID-19 infection was a marker of poor outcomes in terms of mortality and post-operative complications for patients undergoing vascular surgery treatments.
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COVID-19 , Complicações Pós-Operatórias/epidemiologia , Procedimentos Cirúrgicos Vasculares , Idoso , Idoso de 80 Anos ou mais , Estudos de Coortes , Feminino , Pesquisas sobre Atenção à Saúde , Humanos , Itália , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Resultado do TratamentoRESUMO
BACKGROUND: Alpha-1-Antitrypsin (AAT) is one of the major plasmatic protease inhibitors. In the last decade, an association between Alpha-1-Antitrypsin Deficiency (AATD) and Abdominal Aortic Aneurysms (AAA) has been hypothesized. Multiple factors may be involved in AAA's etiopathogenesis, and an underlying structural defect of the extracellular matrix (ECM) is always present. AATD could be a reasonable risk factor for AAA because it is related to protease/antiprotease imbalance and enhanced ECM degradation of the vessel wall. METHODS: We performed genotyping of 138 patients hospitalized in the Vascular Surgery Division of the ASST-Spedali Civili di Brescia, Italy, for nontraumatic rupture of AAA. The second purpose was to observe the distribution of main nongenetic risk factors for AAA between patients with and without AATD. RESULTS: Out of 138 patients, 22 were found with AATD: 16 MS, 1 SS, 3 MZ, and 2 with a new rare AAT variant. When compared to the general Italian population, our cohort's frequency of deficient S allele was significantly higher (7.8 vs. 2.2% respectively, P < 0.01), whereas the deficient Z allele was similar (1.1 vs. 1.3% respectively, P > 0.05). Although we found no differences in age, gender, hypertension, diabetes, and smoke habits between AAA patients with and without AATD, hyperlipidemia was significantly less frequent in patients with AATD (46.4 vs. 12.5% respectively, P < 0.05). CONCLUSIONS: In our AAA patients' cohort, the S allele frequency was higher than in the general Italian population. Our results support the hypothesis that AATD might be a risk factor for AAA.
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Aneurisma da Aorta Abdominal/etiologia , Ruptura Aórtica/etiologia , Deficiência de alfa 1-Antitripsina/complicações , Idoso , Idoso de 80 Anos ou mais , Aneurisma da Aorta Abdominal/diagnóstico por imagem , Ruptura Aórtica/diagnóstico por imagem , Feminino , Frequência do Gene , Predisposição Genética para Doença , Humanos , Itália , Masculino , Pessoa de Meia-Idade , Mutação , Prognóstico , Fatores de Risco , Fatores de Tempo , alfa 1-Antitripsina/genética , Deficiência de alfa 1-Antitripsina/diagnóstico , Deficiência de alfa 1-Antitripsina/genéticaRESUMO
OBJECTIVE: The goal of this study was to analyze our 10-year experience in the treatment of aneurysms of the collateral circulation secondary to steno-occlusions of the celiac trunk (CT) or superior mesenteric artery (SMA). METHODS: In the last 10 years, 32 celiac-mesenteric aneurysms were detected (25 true aneurysms and seven pseudoaneurysms) in 25 patients with steno-occlusion of the CT or SMA. All cases were diagnosed and treated at our center, with either surgical or endovascular approach. As open surgery, we performed aneurysmectomy and revascularization; as endovascular treatment we performed both the embolization (or graft exclusion) of the aneurysm sac, and embolization of afferent and efferent arteries. RESULTS: Sixteen patients (64%) underwent endovascular treatment, accounting for 66% of aneurysms (21/32). Six patients (24%) and seven associated aneurysms (22%) underwent open surgery. Three asymptomatic patients (12%), representing a total of four aneurysms (12%), were not treated. For endovascular procedures, the technical success rate was 90%, with a 56% clinical success rate. For open surgery, clinical and technical success were achieved in five patients (83%) and six procedures (86%), respectively. Sixty-eight percent of patients (17/25) were treated in an emergency setting, using either endovascular (88%) or open (12%) approaches. Although technical success was achieved in more than 85% of these procedures for both approaches, clinical success was reached less frequently among patients with an acute presentation (P = .041). Regardless of the type of treatment, CT or SMA revascularization during the first procedure did not show an increased rate of clinical success (P = .531). However, we reported four cases of visceral ischemia after an endovascular approach without revascularization, with three open surgical corrections required. The mean follow-up was 41 months (range, 0-136 months). CONCLUSIONS: Neither of the approaches described qualifies as a standard optimal choice. We suggest a tailored therapeutic approach based on the clinical condition at the time of diagnosis and specific vascular anatomy.
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Falso Aneurisma/terapia , Aneurisma/terapia , Implante de Prótese Vascular , Artéria Celíaca/cirurgia , Embolização Terapêutica , Procedimentos Endovasculares , Artéria Mesentérica Superior/cirurgia , Isquemia Mesentérica/terapia , Oclusão Vascular Mesentérica/terapia , Adulto , Idoso , Idoso de 80 Anos ou mais , Aneurisma/diagnóstico por imagem , Aneurisma/etiologia , Aneurisma/fisiopatologia , Falso Aneurisma/diagnóstico por imagem , Falso Aneurisma/etiologia , Falso Aneurisma/fisiopatologia , Implante de Prótese Vascular/efeitos adversos , Artéria Celíaca/diagnóstico por imagem , Artéria Celíaca/fisiopatologia , Circulação Colateral , Embolização Terapêutica/efeitos adversos , Emergências , Procedimentos Endovasculares/efeitos adversos , Feminino , Humanos , Masculino , Artéria Mesentérica Superior/diagnóstico por imagem , Artéria Mesentérica Superior/fisiopatologia , Isquemia Mesentérica/diagnóstico por imagem , Isquemia Mesentérica/fisiopatologia , Oclusão Vascular Mesentérica/diagnóstico por imagem , Oclusão Vascular Mesentérica/fisiopatologia , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Risco , Circulação Esplâncnica , Resultado do TratamentoRESUMO
OBJECTIVE: The aim was to report indications, technical aspects, and outcomes of a multicentre experience of late open conversions (LOCs) after endovascular abdominal aneurysm repair (EVAR), in order to identify risk factors which may influence early morbidity and mortality rates, and long term survival. METHODS: Ten vascular centres retrospectively reviewed all patients requiring LOC (≥30 days from initial EVAR, undergoing total or partial endograft explantation) from 1996 to 2017. Baseline characteristics, endograft data, indications, procedural details, post-operative outcomes, and follow up data were reviewed and analysed. RESULTS: Included patients totalled 232 (90.1% males, mean age 74.3 ± 7.9 years). The number of LOC per year significantly increased during the study period, reaching 22 in 2017 (correlation r = 0.867, p < .0001). Reasons for LOC were 80.2% endoleak (186/232), 15.5% endograft infection (36/232), and 9.9% endograft thrombosis (23/232). Sixty-nine patients (29.7%) were operated on urgently; rupture was present in 18.5% (43/232). Eighty-nine patients (38.4%) underwent endovascular re-interventions prior to LOC. The proximal aortic cross clamp site was infrarenal in 40.5% (94/232), suprarenal in 25.4% (59/232), supracoeliac in 32.8% (76/232), and thoracic in 1.3% (3/232). Endograft explantation was total in 164/232 patients (70.7%), and partial in the remaining 68/232 (29.3%). The overall 30 day mortality was 11.2% (26/232). Early mortality was significantly higher for patients operated on urgently (26.1% vs. 4.9%, p < .001). Suprarenal clamping (odds ratio (OR) 2.34, 95% CI 1.12-4.88) and pre-existing renal insufficiency (OR 2.11, 95% CI 1.03-4.31) were independent risk factors for post-operative renal failure on multivariable analysis. Median follow up was 24.1 months (IQR 4.4-60.6). The estimated overall one and five year survival rates were 79.7% and 58.6%, respectively. Survival estimates were significantly lower for patients with endograft infection (83.8% vs. 59% at one year, 65.2% vs. 28.9% at five years; log rank p = .005), as well as for urgent patients (87.2% vs. 62.1% at one year, 65.1% vs. 43.7% at five years; log rank p < .0001). CONCLUSION: The annual number of LOC increased over time. LOCs performed urgently or for endograft infection are associated with poor survival. Infrarenal aortic clamping has lower post-operative complication rates.
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Aneurisma da Aorta Abdominal/cirurgia , Conversão para Cirurgia Aberta , Procedimentos Endovasculares , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/cirurgia , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Fatores de TempoRESUMO
BACKGROUND: We present a comparison of renal function outcomes during HTAR with the use of a new hybrid vascular graft (GHVG) or standard graft. METHODS: It is a multicenter, retrospective, observational study. Between January 2015 and March 2019, 36 patients were treated with HTAR. We compared HTAR performed with the use of the GHVG and with the use of standard bypass graft. Primary outcome measures were hospital mortality, acute kidney injury (AKI) at 30 days and GHVG patency. RESULTS: Mean GHVG ischemia time was significantly lower for both renal arteries (right: GHVG, 4 ± 2 vs. standard graft, 15 ± 7 min; 95% CI 2.23-6.69, P < 0.001; left: GHVG, 3 ± 2 vs. standard graft, 13 ± 7 min; 95% CI 2.44-5.03, P < 0.001). Hospital mortality was 17% (6/36); while mortality did not differ between the two groups, postoperative acute kidney injury rate was 30.5% (11/36 patients) and was more common in the standard graft group (7% vs. 29%; OR 3.2, P = 0.074). Estimated primary patency was 92% ± 2 (95% CI 79.5-97%) at 36 months and was not different between the two groups (GHVG 94% ± 6 vs. standard graft 91% ± 6; log-rank χ2 = 0.260, P = 0.610). CONCLUSIONS: In our experience of HTAR, ischemia time was significantly shorter and postoperative AKI occurrence was lower with GHVG if compared to standard graft bypass, with satisfactory midterm patency rate comparable to that of standard graft bypass.
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Injúria Renal Aguda/etiologia , Aneurisma da Aorta Torácica/cirurgia , Prótese Vascular/efeitos adversos , Enxerto Vascular/efeitos adversos , Injúria Renal Aguda/fisiopatologia , Idoso , Idoso de 80 Anos ou mais , Implante de Prótese Vascular/efeitos adversos , Feminino , Mortalidade Hospitalar , Humanos , Estimativa de Kaplan-Meier , Rim/cirurgia , Masculino , Estudos Retrospectivos , Resultado do Tratamento , Grau de Desobstrução Vascular , Isquemia QuenteRESUMO
Non-typhoidal Salmonella (NTS) spp. causes about 40% of all infective aortitis and it is characterized by high morbidity and mortality. Human infection occurs by fecal-oral transmission through ingestion of contaminated food, milk, or water (inter-human or zoonotic transmission). Approximately 5% of patients with NTS gastroenteritis develop bacteremia and the incidence of extra-intestinal focal infection in NTS bacteremia is about 40%. The organism can reach an extra-intestinal focus through blood dissemination, direct extension from the surrounding organs and direct bacterial inoculation (e.g. invasive medical procedures). Medical and surgical interventions are both needed to successfully control the infection. Here, we report a case of abdominal sub-renal aortitis caused by Salmonella enterica serovar Enteritidis in an 80-year-old man.
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Aorta Abdominal/cirurgia , Aortite/diagnóstico , Infecções por Salmonella/diagnóstico , Salmonella enteritidis/isolamento & purificação , Idoso de 80 Anos ou mais , Aorta Abdominal/patologia , Aortite/microbiologia , Aortite/patologia , Aortite/cirurgia , Humanos , Itália , Masculino , Infecções por Salmonella/microbiologia , Infecções por Salmonella/patologia , Infecções por Salmonella/cirurgia , Resultado do TratamentoRESUMO
OBJECTIVE: Recent improvement of best medical treatment for carotid stenosis has sparked a debate on the role of surgery-identification of patients who may benefit from carotid endarterectomy (CEA) is crucial to avoid overtreatment. An expected 5-year postoperative survival is one of the main selection criteria. The aim of this study was the development of a score for predicting survival of asymptomatic patients after CEA. METHODS: Our score was derived from a retrospective analysis of 648 consecutive asymptomatic patients from a single hospital. External validation of the score was then performed on a second cohort of 334 asymptomatic patients from two different hospitals in the same area. Factors associated with reduced postoperative survival within the derivation cohort (DC) were identified and tested for statistical significance. Each selected factor was assigned a score proportional to its ß coefficient: 1 point for chronic obstructive pulmonary disease, diabetes mellitus, coronary artery disease, and lack of statin treatment; 4 points for age 70 to 79 years and creatinine concentration ≥1.5 mg/dL; 8 points for age ≥80 years and dialysis. The DC was divided into four groups based on individual scores: group 1, 0 to 3 points; group 2, 4 to 7 points; group 3, 8 to 11 points; and group 4, ≥12 points. Group-specific survival curves were calculated. The validation cohort (VC) was stratified according to the score. Survival of each of the four risk groups within the VC was compared with its analogue from the DC. RESULTS: Median follow-up of the DC and VC was, respectively, 56 and 65 months. Intercohort comparison of 5-year survival was 84.7% ± 1.7% vs 85.2% ± 2% (P = .41). Group-specific 5-year survival within the DC was 97% ± 1.5% (group 1), 88.4% ± 2.2% (group 2), 69.6% ± 4.7% (group 3), and 48.1% ± 13.5% (group 4; P < .0001). Five-year survival within the VC was 95.5% ± 2% (group 1), 89.5% ± 2.7% (group 2), 65% ± 6.1% (group 3), and 44.8% ± 14.1% (group 4; P < .0001). Intercohort comparison of group-specific survival curves showed close similarity throughout the groups. CONCLUSIONS: Our score is a simple clinical tool that allows a quick and reliable prediction of survival in asymptomatic patients who are candidates for CEA. This selective approach is crucial to avoid unnecessary surgery on patients who are less likely to survive long enough to experience the benefits of this preventive procedure.
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Doenças Assintomáticas/mortalidade , Estenose das Carótidas/mortalidade , Endarterectomia das Carótidas/efeitos adversos , Expectativa de Vida , Seleção de Pacientes , Idoso , Idoso de 80 Anos ou mais , Doenças Assintomáticas/terapia , Estenose das Carótidas/complicações , Estenose das Carótidas/cirurgia , Tomada de Decisão Clínica/métodos , Comorbidade , Técnicas de Apoio para a Decisão , Dislipidemias/epidemiologia , Feminino , Humanos , Hipertensão/epidemiologia , Estimativa de Kaplan-Meier , Masculino , Pessoa de Meia-Idade , Período Pós-Operatório , Estudos Retrospectivos , Medição de Risco/métodos , Fatores de Risco , Índice de Gravidade de Doença , Acidente Vascular Cerebral/etiologia , Acidente Vascular Cerebral/mortalidade , Acidente Vascular Cerebral/prevenção & controle , Fatores de Tempo , Resultado do TratamentoRESUMO
OBJECTIVE: The objective of this study was to assess immediate and midterm outcomes for urgent/emergent and elective patients with thoracoabdominal aortic aneurysms (TAAAs) treated with the first commercially available "off-the-shelf" multibranched endograft for endovascular aneurysm repair, with a single-step or a staged surgical approach. METHODS: A multicenter, nonrandomized, retrospective study was conducted of TAAA patients grouped by urgent/emergent and elective treatment with multibranched endograft for endovascular aneurysm repair at 13 Italian centers from November 2012 to August 2016. Urgent/emergent repair was classified as rupture in 16%, impending rupture in 9%, pain in 53%, or a maximum TAAA diameter ≥80 mm in 22%. Study end points were technical success, mortality, spinal cord ischemia, target visceral vessel (TVV) patency, and procedure-related reinterventions at 30 days and at follow-up. RESULTS: Seventy-three patients (274 TVVs) were enrolled. Treatment was performed in elective (n = 41 [56%]) or urgent/emergent (n = 32 [44%]) settings, according to a single-step (n = 30 [41%]) or staged (n = 43 [59%]) approach. Technical success was 92%. Mortality within 30 days was 4% (n = 3 urgent/emergent patients) due to myocardial infarction. Spinal cord ischemia was recorded in two patients (3%; elective group). The primary patency of TVVs was 99% (three renal branch occlusions). Procedure-related reinterventions were required in five cases (7%). At least one adverse event from any cause ≤30 days was registered in 42% (n = 31). At a median follow-up of 18 months (range, 1-43 months), eight (11%) deaths (elective vs urgent/emergent, 2% vs 22%; P = .018), three (1%) cases of branch occlusion or stenosis, and five (7%) reinterventions were recorded. A survival of 88% (standard error [SE], 4%), 86% (SE, 4%), and 82% (SE, 5%) was evidenced at 12, 24, and 36 months, respectively. Urgent/emergent repair and female gender were identified as independent risk factors for all-cause mortality (P < .001 and P = .015, respectively), and the staged approach was identified as protective (P = .026). Freedom from reintervention was 86% (SE, 4%) and 83% (SE, 5%) at 12 and 24 months. CONCLUSIONS: The first off-the-shelf multibranched endograft seems safe in both urgent/emergent and elective settings. The staged surgical approach appears to positively influence overall survival. This unique device and its operators will usher in a new treatment paradigm for TAAA repair.
Assuntos
Aneurisma da Aorta Torácica/cirurgia , Implante de Prótese Vascular/instrumentação , Prótese Vascular , Procedimentos Endovasculares/instrumentação , Stents , Idoso , Idoso de 80 Anos ou mais , Aneurisma da Aorta Torácica/diagnóstico por imagem , Aneurisma da Aorta Torácica/mortalidade , Aneurisma da Aorta Torácica/fisiopatologia , Aortografia/métodos , Implante de Prótese Vascular/efeitos adversos , Implante de Prótese Vascular/mortalidade , Angiografia por Tomografia Computadorizada , Procedimentos Cirúrgicos Eletivos , Emergências , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/mortalidade , Feminino , Humanos , Itália , Estimativa de Kaplan-Meier , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/etiologia , Desenho de Prótese , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Grau de Desobstrução VascularRESUMO
PURPOSE: To report a heretofore undescribed complication seen on imaging after endovascular aortic sealing (EVAS). CASE REPORT: A 77-year-old woman was treated with the Nellix EVAS device for an infrarenal aortic aneurysm. After a normal computed tomography (CT) scan at 15 days, the 6-month CT showed the onset of perianeurysmal inflammatory tissue. The patient was asymptomatic, and blood tests were normal. Imaging suggested a nonaggressive inflammatory process, so a conservative approach was adopted with close follow-up. The periaortic tissue remitted without any treatment after a further 9 months (16 months after EVAS). CONCLUSION: The cause of this nonacute complication is unclear. Some clues suggest that interaction between the endobags and aneurysm wall could be involved. Imaging and clinical data led to a successful conservative strategy.
Assuntos
Aneurisma da Aorta Abdominal/cirurgia , Aortografia/métodos , Implante de Prótese Vascular/efeitos adversos , Angiografia por Tomografia Computadorizada , Procedimentos Endovasculares/efeitos adversos , Fibrose Retroperitoneal/diagnóstico por imagem , Idoso , Aneurisma da Aorta Abdominal/diagnóstico por imagem , Feminino , Humanos , Angiografia por Ressonância Magnética , Valor Preditivo dos Testes , Fibrose Retroperitoneal/etiologia , Resultado do TratamentoRESUMO
BACKGROUND: We report the results of the operative treatment for type 2 endoleak (T2E) involving the inferior mesenteric artery (IMA) using the transarterial embolization (TAE) or the video laparoscopic ligation (VLS). METHODS: Between January 2005 and December 2015, we retrospectively analyzed 901 patients treated with endovascular aortic repair (EVAR): 883 (98%) had 1 valid postoperative radiologic evaluation, at least. All patients with operative repair for IMA-related T2E entered the final analysis. Indication of their operative repair was sac enlargement (>5 mm within 6 months or >1 cm from the preoperative diameter, irrespectively of the postoperational time) and/or its persistence >12 months. RESULTS: We detected 192 (21.7%) T2Es, overall. We identified 37 (4.2%) IMA-related T2Es, and treated 21 cases (VLS n = 11, TAE n = 10). Aneurysm-related mortality and major or minor morbidity was never observed. Time of intervention did not differ significantly (minutes, VLS = 97 ± 46 vs. TAE = 95 ± 21, P = 0.901). Hospitalization was significantly lower in the TAE group (days, 4 ± 2 vs. 1 ± 0.4, P < 0.001). No patient was lost at a mean follow-up of 46 ± 32 months (range, 1-110; median, 48). At last follow-up, sac diameter was significantly more stable in the VLS (mm, 60 ± 10 vs. 55 ± 7, P = 0.593) than that in the TAE group (mm, 57 ± 9 vs. 63 ± 10, P = 0.050). The IMA-related T2E reintervention rate was not significantly different between the groups (VLS, n = 0 [0%] vs. TAE, n = 2 [20.0%], P = 0.213). Secondary aortic reintervention rate was 28.6% (n = 6), and secondary open conversion rate was 9.5% (VLS, n = 1 [9.1%] vs. TAE, n = 1 [10.0%], P = 1). CONCLUSIONS: In authors' experience, operative treatment of IMA-related T2E was safe; VLS proved to be effective and durable in sealing this type of T2E. Patients receiving correction of IMA-related T2E after EVAR remained at risk for development of any type of endoleaks, as well as at risk of reintervention.
Assuntos
Aneurisma da Aorta Abdominal/cirurgia , Implante de Prótese Vascular/efeitos adversos , Embolização Terapêutica , Endoleak/terapia , Procedimentos Endovasculares/efeitos adversos , Laparoscopia/métodos , Artéria Mesentérica Inferior/cirurgia , Cirurgia Vídeoassistida/métodos , Idoso , Idoso de 80 Anos ou mais , Aneurisma da Aorta Abdominal/diagnóstico por imagem , Aortografia , Bases de Dados Factuais , Embolização Terapêutica/efeitos adversos , Endoleak/diagnóstico por imagem , Endoleak/etiologia , Endoleak/cirurgia , Feminino , Humanos , Itália , Laparoscopia/efeitos adversos , Tempo de Internação , Ligadura , Masculino , Artéria Mesentérica Inferior/diagnóstico por imagem , Pessoa de Meia-Idade , Reoperação , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Cirurgia Vídeoassistida/efeitos adversosRESUMO
OBJECTIVE: This study investigated the frequency, clinical features, therapeutic options, and results of aortoenteric fistulas (AEFs) developing after endovascular abdominal aortic repair (EVAR). METHODS: Eight Italian centers with an EVAR program participated in this retrospective multicenter study and collected data on AEFs that developed after a previous EVAR. RESULTS: A total of 3932 patients underwent EVAR between 1997 and 2013 at the participating centers. During the same period, 32 patients presented with an AEF during EVAR follow-up, 21 with original EVAR performed for atherosclerotic aneurysmal disease (ATS group) and 11 with the original EVAR performed for a postsurgical pseudoaneurysm (PSA group). The incidence of AEF development after EVAR was 0.46% in the ATS group and 3.9% in the PSA group. Anastomotic PSA as the indication to EVAR (P < .0001) and urgent/emergency EVAR (P = .01) were significantly associated with AEF development. Median time between EVAR and the AEF diagnosis was 32 months (interquartile range, 11-75 months) for the ATS group and 14 months (interquartile range, 10.5-21.5 months) for the PSA group. Among five AEF patients treated conservatively, two (40%) died, at 7 and 15 months, and the remaining three were alive at a median follow-up of 12 months. The AEF was treated surgically in 27 patients, including aortic stent graft explantation in all cases, in situ aortic reconstruction in 14 (52%), and extra-anatomic bypass in 13 (48%). Perioperative mortality was 37% (10 of 27). No additional aortic-related death was recorded in operated-on patients at a median follow-up of 28 months. CONCLUSIONS: Late AEFs rarely occur during EVAR follow-up, but the risk is significantly increased when EVAR is performed for PSA after previous aortic surgery and EVAR is performed as an emergency. Conservative and surgical treatment of post-EVAR AEF are both associated with high mortality. However, beyond the perioperative period, surgical correction of AEFs appears to be durable at midterm follow-up.
Assuntos
Falso Aneurisma/cirurgia , Aneurisma da Aorta Abdominal/cirurgia , Implante de Prótese Vascular/efeitos adversos , Procedimentos Endovasculares/efeitos adversos , Fístula Intestinal/epidemiologia , Fístula Vascular/epidemiologia , Idoso , Idoso de 80 Anos ou mais , Falso Aneurisma/diagnóstico por imagem , Falso Aneurisma/mortalidade , Aneurisma da Aorta Abdominal/diagnóstico por imagem , Aneurisma da Aorta Abdominal/mortalidade , Implante de Prótese Vascular/mortalidade , Procedimentos Cirúrgicos Eletivos , Emergências , Procedimentos Endovasculares/mortalidade , Feminino , Mortalidade Hospitalar , Humanos , Incidência , Fístula Intestinal/diagnóstico por imagem , Fístula Intestinal/mortalidade , Fístula Intestinal/terapia , Itália/epidemiologia , Masculino , Pessoa de Meia-Idade , Retratamento , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Fístula Vascular/diagnóstico por imagem , Fístula Vascular/mortalidade , Fístula Vascular/terapiaRESUMO
Vascular plugs are an evolving family of vessel occluders providing a single-device embolization system for large, high-flow arteries. Nitinol mesh plugs and polytetrafluoroethylene membrane plugs are available in different configurations and sizes to occlude arteries from 3 to 20 mm in diameter. Possible applications during complex endovascular aortic procedures are aortic branch embolization to prevent endoleak or to gain an adequate landing zone, directional branch occlusion, and false lumen embolization in aortic dissection. Plugs are delivered through catheters or introducers, and their technical and clinical results are comparable to those of coil embolization. Plugs are more accurate than coils as repositionable devices, less prone to migration, and have fewer blooming artifacts on postoperative computed tomography imaging. Their main drawback is the need for larger delivery systems. This narrative review describes up-to-date techniques and technology for plug embolization in complex aortic repair.
RESUMO
OBJECTIVES: The goal of this multicentre retrospective cohort study was to evaluate technical success and early and late outcomes of thoracic endovascular repair (TEVAR) with grafts deployed upside down through antegrade access, to treat thoracic aortic diseases. METHODS: Antegrade TEVAR operations performed between January 2010 and December 2021 were collected and analysed. Both elective and urgent procedures were included. Exclusion criteria were endografts deployed in previous or concomitant surgical or endovascular repairs. RESULTS: Fourteen patients were enrolled; 13 were males (94%) with a mean age of 71 years (interquartile range 62; 78). Five patients underwent urgent procedures (2 ruptured aortas and 3 symptomatic patients). Indications for treatment were 8 (57%) aneurysms/pseudoaneurysms, 3 (21%) dissections and 3 (21%) penetrating aortic ulcers. Technical success was achieved in all procedures. Early mortality occurred in 4 (28%) cases, all urgent procedures. Median follow-up was 13 months (interquartile range 1; 44). Late deaths occurred in 2 (20%) patients, both operated on in elective settings. The first died at 19 months of aortic-related reintervention; the second died at 34 months of a non-aortic-related cause. Two patients (14%) underwent aortic-related reinterventions for late type I endoleak. The survival rate of those having the elective procedures was 100%, 84% and 67% at 12, 24 and 36 months, respectively. Freedom from reintervention was 92%, 56% and 56% at 12, 24 and 36 months, respectively. CONCLUSIONS: Antegrade TEVAR can seldom be considered an alternative when traditional retrograde approach is not feasible. Despite good technical success and few access-site complications, this study demonstrates high rates of late type I endoleak and aortic-related reinterventions.
Assuntos
Aorta Torácica , Doenças da Aorta , Correção Endovascular de Aneurisma , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Aorta Torácica/cirurgia , Aneurisma da Aorta Torácica/cirurgia , Aneurisma da Aorta Torácica/mortalidade , Doenças da Aorta/cirurgia , Prótese Vascular , Correção Endovascular de Aneurisma/métodos , Complicações Pós-Operatórias/epidemiologia , Estudos Retrospectivos , Resultado do TratamentoRESUMO
The objective of these Guidelines is to provide recommendations for the classification, indication, treatment and management of patients suffering from aneurysmal pathology of the visceral and renal arteries. The methodology applied was the GRADE-SIGN version, and followed the instructions of the AGREE quality of reporting checklist. Clinical questions, structured according to the PICO (Population, Intervention, Comparator, Outcome) model, were formulated, and systematic literature reviews were carried out according to them. Selected articles were evaluated through specific methodological checklists. Considered Judgments were compiled for each clinical question in which the characteristics of the body of available evidence were evaluated in order to establish recommendations. Overall, 79 clinical practice recommendations were proposed. Indications for treatment and therapeutic options were discussed for each arterial district, as well as follow-up and medical management, in both candidate patients for conservative therapy and patients who underwent treatment. The recommendations provided by these guidelines simplify and improve decision-making processes and diagnostic-therapeutic pathways of patients with visceral and renal arteries aneurysms. Their widespread use is recommended.
Assuntos
Aneurisma , Embolização Terapêutica , Humanos , Artéria Renal/diagnóstico por imagem , Radiologia Intervencionista , Aneurisma/diagnóstico por imagem , Aneurisma/cirurgia , Embolização Terapêutica/efeitos adversos , ItáliaRESUMO
Several studies have suggested that infectious agents may induce the development of abdominal aortic aneurysms and/or accelerate their progression. The aim of this study was to evaluate the presence of the respiratory-transmitted viruses such as influenza A and B and parainfluenza type 1 genomes in bioptic fragments of abdominal aortic aneurysms. Furthermore, the association between viral infection and traditional risk factors for aneurysms was investigated employing multivariate logistic regression models. The genome of parainfluenza 1 was detected in 11 out of 57 patients with abdominal aortic aneurysm, influenza A only in one, whereas none of the specimens analyzed resulted positive for influenza B. After adjustment of age, gender, and clinical diagnosis, being current smokers was associated independently with parainfluenza 1 detection in aneurysms. The identification of parainfluenza 1 in aortic aneurysm biopsies supports previous observations of a possible role of viruses in the lesion development. Smoking, by interfering with the respiratory tract's ability to defend itself and predisposing to upper and lower respiratory tract infections may accelerate the onset and progression of abdominal aortic aneurysms.