A systematic review of therapies for aortobronchial fistulae.

OBJECTIVE: The aim of the study was to summarize epidemiologic data about aortobronchial fistulae and compare outcomes (mortality, recurrence, reoperation) of open, staged, and endovascular repair of aortobronchial fistula. METHODS: A systematic literature review was conducted to identify eligible studies published between January 1999 and December 2019. The Cochrane Library, PubMed, and Scopus databases were used as search engines. Eligible studies included articles reporting postoperative outcomes (death/follow-up). Literature review revealed only case reports and small case series, and thus, only descriptive data with data heterogeneity were available. The corresponding authors were contacted to provide additional information or outcome updates (recurrence/reoperation/death). RESULTS: Overall, 214 patients (90 studies) underwent 271 procedures (including redo procedures and staged procedures). Most of the patients were treated by endovascular means (72.42%). Open surgical repair was performed in 21.96% and staged procedures in 5.6%. Aortobronchial fistulae were located most often in the descending thoracic aorta (zone 3 or 4) (64.6%) and in zone 2 (23.8%). Fourteen percent of aortobronchial fistulae developed after thoracic endovascular aneurysm repair. Recurrence or infection occurred in 20% (43) patients. Recurrences were, to some extent, associated with the presence of endoleak. Long-term antibiotic administration (>1 month) was instituted in 63 patients (29.4%), whereas 90 patients (42%) did not receive antibiotics beyond hospitalization. From the remaining 61 patients, 3 received lifelong antibiotics and for 58 patients data were not available. Considering outcomes, the mean follow-up was 25.1 months (0-188 months) and not significantly different among treatments. LIMITATIONS: Literature review has revealed only case reports and small case series, and thus, only descriptive data were available. Randomized controlled trials are not available due to the rarity of the disease, which significantly decreases the power of the present study. Also, this study reflects significant data heterogeneity due to the nature of the analyzed manuscripts and would benefit from large patient cohort studies that have not been conducted till today. CONCLUSIONS: Aortobronchial fistula is a complex disease. Endoleaks may be involved in the development and the recurrence process, and they should not be disregarded. Considering major outcomes (length of follow-up), the available treating strategies are equal, and thus, surgeons should feel confident to apply the treatment of their choice, keeping in mind their experience, patient's age, and clinical condition.

Fenestrated Endovascular Repair for Pararenal or Juxtarenal Abdominal Aortic Aneurysms: a Systematic Review.

BACKGROUND: This review aims to collect all available data on early and late outcomes in patients undergoing fenestrated endovascular aortic aneurysm repair (F-EVAR) for pararenal or juxtarenal abdominal aortic aneurysms (AAAs). METHODS: The Pubmed, Embase, Scopus and Cochrane Library databases were systematically searched to identify eligible studies. Studies reporting at least early mortality after F-EVAR in patients with pararenal or juxtarenal AAA were included. Thirty-day outcomes were defined as early, and outcomes reported after 30 days postoperatively were defined as late. Basic characteristics of all studies and demographics of patients were reported. RESULTS: Overall, 30 studies (17 retrospective and 13 prospective) including 23,385 patients in total were included. Out of 23,385 patients, a total of 2,271 patients were treated with F-EVAR for pararenal/juxtarenal AAA. Overall, 4,216 target vessels were to be treated (data from 24 studies). Pooled early mortality reached 2.55% (ranging from 0% to 6.74%), with a pooled technical success of 96.8% (ranging from 82.8% to 100%). Regarding late outcomes, pooled all-cause mortality reached 17% (ranging from 0% to 50%), 1-year primary patency was 94.6% (ranging from 91.8% to 97.1%) and reintervention rate was 10.4% (ranging from 0% to 57.4%). Mean/median follow-up ranged from 3 to 60 months. CONCLUSIONS: Early outcomes indicate that F-EVAR is a safe and efficient treatment for patients with pararenal/juxtarenal AAAs. Although long-term outcomes are acceptable, late-intervention rate remains high.

Early Post-EVAR Rupture in a Patient with Early Type II Endoleak: A Borderline Treatment.

PURPOSE: The detection of type II endoleak one month after endovascular aneurysm repair (EVAR) is usually neglected or considered benign. Aim of this report is to present a case of post-EVAR rupture, due to type II endoleak, and discuss on pathophysiology and differential diagnosis. CASE REPORT: We present a case of a 67-year-old male who was treated with EVAR for an asymptomatic abdominal aortic aneurysm and four months later, he presented with a contained rupture due to a type II endoleak. The patient was treated conservatively without any intervention with satisfying result. CONCLUSIONS: We are demonstrating conservative management as a valid therapeutic option for patients presenting with a contained post-EVAR rupture.

Giant Dorsalis Pedis Pseudoaneurysm Following Cannulation for Arterial Line in a Patient with Systemic Lupus Erythematosus.

Dorsalis pedis artery (DPA) aneurysms are very rare and fewer than 60 cases have been reported in the literature. Most affected patients present with false aneurysms after orthopedic surgery or trauma. Here we report an unusual case of a giant DPA pseudoaneurysm after cannulation for arterial line placement in a patient newly diagnosed with systemic lupus erythematosus (SLE). A diagnostic delay resulted in necrosis of the overlying skin. Excision of the pseudoaneurysm, ligation of the DPA, and debridement of the foot dorsum were performed, followed by a second flap coverage surgery. Although a DPA false aneurysm is rare after arterial line removal, it can cause the serious complications of skin necrosis, rupture and toe necrosis. Arterial puncture sites should be carefully monitored, especially in patients with SLE or other vasculitis.

TEVAR for Secondary Aortobronchial Fistulas: Two Cases with Favorable Long-term Outcomes.

Secondary aortobronchial fistula (ABF) is an uncommon clinical entity associated with increased mortality. Most common presentation is hemoptysis, ranging from repetitive self-limiting episodes to massive hematemesis. Mediastinitis (if present) and excessive blood loss burden the unfavorable case of ABF, whereas stent-graft contamination and sepsis are the main concerns regarding endovascular therapy. We are presenting two patients with secondary ABF treated with thoracic endovascular repair who completed long-term follow-up without complications or evidence of infection.

High prevalence of abdominal aortic aneurysm in patients with inguinal hernia.

AIMS: There is increased prevalence of inguinal hernia (ΙΗ) in patients with abdominal aortic aneurysm (AAA). As there is limited data on AAA in patients with ΙΗ our objective was to examine the prevalence of AAA in such patients. METHODS: We prospectively examined 185 consecutive patients for AAA who presented to our department for surgical repair of an ΙΗ. All patients were referred for ultrasound of the abdominal aorta. An AAA was considered to be present when the distal diameter of the abdominal aorta was over 3 cm. Patients with no AAA were followed annually with an abdominal ultrasound for 5 years. RESULTS: Out of the 185 patients (179 males, 6 females) aged from 35-81 (mean 58.6 years), AAA initially appeared in 28 patients with a mean age 61.2 years old. The range of the aortic distal diameter was between 3.4 and 8.1 cm with a mean diameter of 4.8 cm in patients with AAA. The prevalence of the ΑΑΑ was increased in smokers, with hypertension and with bilateral and direct hernia. At the end of the 5 years follow-up, 16 more patients had developed an AAA of mean diameter 3.2 cm (3-4.1 cm), increasing the prevalence of AAA to 27.7%. CONCLUSION: There is an increased prevalence of AAA in patients with ΙΗ, especially in smokers, with hypertension and with bilateral and/or direct hernia. Hence, periodic ultrasonound may play an important role in screening and early diagnosis of AAA in these patients.

Total Endovascular Therapy of Abdominal Aortic Aneurysm, Peripheral Artery Disease, and Chronic Mesenteric Ischemia: A Challenging Case.

We presented a challenging case of a patient diagnosed with abdominal aortic aneurysm (AAA), peripheral artery disease, and chronic mesenteric ischemia (CMI). Herein, we describe the treatment in this high-risk patient diagnosed with CMI who also had critical limb ischemia and his AAA had rapidly expanded. First we performed angioplasty and celiac arterial stenting. Afterwards, we proceeded to perform balloon angioplasty of the iliac arteries and chimney endovascular aneurysm repair (Ch-EVAR) preserving the inferior mesenteric artery (IMA). The patient was discharged three days later and his IMA remained patent eighteen months post-operation. A thorough pre-operative assessment is essential in such challenging cases. Minimally invasive procedures like endovascular therapy and the chimney technique extend the prognoses in high-risk patients.

A Rare Case of Brachial Artery Aneurysm Following Hemodialysis Fistula Ligation in a Transplanted Patient.

Aneurysmal arterial dilatation is an infrequent complication following arteriovenous fistula ligation. Herein, we are describing a case in which a 49-year-old transplanted patient developed a true, symptomatic, brachial artery aneurysm 25 years after transplantation and 12 years after ligation of his radiocephalic wrist fistula. Treating strategy included aneurysmectomy and reversed vein interposition using ipsilateral, dilated branch of cephalic vein. Two years postoperatively, the patient remains without complications. Moreover, we mention the pathophysiologic mechanisms that may have contributed to this phenomenon.

A carotid bifurcation pseudoaneurysm treated endovascularly in a patient with irradiated neck.

A carotid artery pseudoaneurysm in an irradiated neck is a rare entity with possible devastating results and management should be multidisciplinary. We present a successful endovascular treatment of a late carotid artery pseudoaneurysm following patch endarterectomy and cervical radiotherapy.

Carotid Endarterectomy versus Carotid Stenting or Best Medical Treatment in Asymptomatic Patients with Significant Carotid Stenosis: A meta-analysis.

BACKGROUND: This meta-analysis aimed to evaluate randomized trials (RTs) that compare outcomes among asymptomatic patients with significant carotid stenosis undergoing carotid endarterectomy (CEA) versus carotid stenting (CAS) or best medical treatment (BMT). MATERIAL AND METHODS: The Pubmed, Embase, Scopus and Cochrane Library databases were systematically searched to identify eligible studies. Data were analyzed by using the StatsDirect Statistical software (Version 2.8.0, StatsDirect Ltd). Odds ratios (OR) were used to determine effect size, along with 95% confidence interval (CI). PRISMA guidelines for conducting meta-analyses were utilized. RESULTS: Overall, 10 RTs including 8771 asymptomatic patients were evaluated. Compared to CAS, 30-day all stroke risk was found to be lower after CEA (pooled OR = 0.56; CI 95% [0.312-0.989]; P = 0.046). However, other early and late outcomes were not different between CEA and CAS. Furthermore, 30-day all stroke (pooled OR = 3.43; CI 95% [1.810-6.510]; P = 0.0002), death (pooled OR = 4.75; CI 95% [1.548-14.581]; P = 0.007) and myocardial infarction (MI) (pooled OR = 9.18; CI 95% [1.668-50.524]; P = 0.011) risks were higher after CEA compared to BMT, as expected. Additionally, 30-day all stroke/death and all stroke/death/MI risks were higher after CEA compared to BMT as well. Regarding long-term results, ipsilateral stroke risk was lower after CEA compared to BMT (pooled OR = 0.46; CI 95% [0.361-0.596]; P < 0.0001) although death due to stroke risk was not different (pooled OR = 0.57; CI 95% [0.223-1.457]; P = 0.240). Unfortunately, no study comparing CAS to BMT was found. CONCLUSIONS: CEA is associated with a lower early all stroke risk compared to CAS although other early or late outcomes did not show any difference between the two methods. Additionally, CEA seems to have a benefit over BMT against long-term ipsilateral stroke, although early outcomes are worse after CEA. No studies are available comparing CAS to BMT alone.

Symptomatic Bilateral Carotid Artery Occlusion: An Uncommon Pattern of Carotid Pathology.

We report an unusual case of an 83-year-old man who was admitted with dizziness and repeated drop attacks. He was diagnosed with bilateral carotid artery occlusion and he underwent a left subclavian to left carotid bypass with ringed polytetrafluoroethylene graft. The patient's postoperative course was uneventful and no symptoms presented during a 6-month follow-up. Finally, we discuss on proper management of such patients.

Late Rupture of a Totally Thrombosed Abdominal Aortic Aneurysm: A Case Report and Literature Review.

Chronic totally thrombosed abdominal aortic aneurysms (AAAs) comprise a rare medical situation, with only a few cases reported in literature. Optimal management has been controversial, although an early risk for rupture is present. Therefore, we present a rare case of late rupture in a patient with a totally thrombosed AAA, and we discuss proper treatment.

Conservative treatment of patients with thromboangiitis obliterans or cannabis-associated arteritis presenting with critical lower limb ischaemia.

BACKGROUND: Proper management of patients with thromboangiitis obliterans (TAO) or cannabis-associated arteritis (CAA), presenting with critical lower limb ischaemia (CLI) remains controversial, and data are limited. PATIENTS AND METHODS: Patients with TAO or CAA presenting with CLI between 2011 and 2016 were retrospectively evaluated. Patients requiring primary intervention were excluded. Conservative treatment included: (a) weight-adjusted bemiparin plus six hours/day intravenous iloprost for 28 days, (b) aspirin (100 mg/day) plus cilostazol (100 mg twice/day) after discharge, and (c) strict recommendations/monitoring for smoking cessation. Main outcomes included symptom recession, ankle-brachial index (ABI) improvement, and healing of lesions at the time of discharge as well as amputation, revascularization, and abstinence rate during follow-up. RESULTS: Overall, 23 patients (TAO: 15; CAA: 8) were included within six years, none of the patients reported any other factor than smoking. All patients presented with rest pain and 12 patients with ulcer or necrotic lesions. Mean ABI measurement at presentation was 0.46 ± 0.2, after 28 days of treatment, all patients showed improvement regarding clinical picture and ABI measurement (0.54 ± 0.1; p < 0.05). During follow-up, only three patients underwent bypass surgery and two patients underwent major amputation, although the smoking abstinence rate was very low (13 %). CONCLUSIONS: Intravenous iloprost plus bemiparin for 28 days together with per os aspirin plus cilostazol seem to produce promising results in patients with TAO/CAA, treated for CLI, even with a low smoking abstinence rate. However, larger series are needed to further evaluate inter-group differences and potential prognostic factors.

Double primary venous aneurysm of the small saphenous vein.

Venous aneurysms are rare lesions and of little significance in every day clinical practice. While in many cases asymptomatic they can be the cause of great morbidity due to thrombosis and subsequent possibility of pulmonary embolism. Venous aneurysms are classified in deep and superficial according to affected vein. The diagnosis is based mainly on Doppler ultrasound, while computed tomography, magnetic resonance imaging and venography provide more details. Treatment of venous aneurysms should be surgical. We present a case of a double aneurysm of the lesser saphenous vein which according to our knowledge is the first case reported in literature. KEY WORDS: Superficial veins, Varices, Venous.