Hostility of proximal aortic neck anatomy in relation to abdominal aortic aneurysm size and its impact on the outcome of endovascular repair with the new generation endografts.

BACKGROUND: To assess the relation of abdominal aortic aneurysm (AAA) diameter with the proximal neck anatomy (PNA) hostility and to evaluate its impact on the endovascular aneurysm repair (EVAR) outcomes with the use of newer generation endografts. METHODS: Retrospective analysis of single institution's recorded data from February 2009 to April 2016. Patients' characteristics, comorbidities, aortic morphology, perioperative characteristics and outcomes were analyzed. In relation to AAA diameter 2 groups were identified: group A (50-55 mm) and group B (>55 mm). Hostile PNA was defined based on: neck diameter >28 mm, length <15 mm, angulation >60o, and circumferential thrombus and/or calcification >50%. The aortic neck scoring system was calculated. Multiple logistic regression analysis with a forward likelihood ratio method adjusted for age and gender was undertaken. RESULTS: Three hundred seventeen patients (96% males, mean age 72.4±9 years, 80% elective) were follow-up for a mean of 23.4 months (range, 3-86 months). No differences were observed in demographics and co-morbidities between the two groups (group A: 134, 42% vs. group B: 183, 58%). Hostile PNA was present in 147/317 (46%) patients and significantly more likely to be present in group B (P<0.001). In group B the aortic neck score was higher (P<0.001), the likelihood for having hostile PNA increased for neck diameter by 2.2-fold (OR 2.2, P=0.013, 95% CI: 1.18-4.03), length by 2.3-fold (OR 2.3, P=0.012, 95% CI: 1.20-4.51), angle by 4.8-fold (OR 4.8, P=0.002, 95% CI: 1.79-13.24) and presence of thrombus by 1.5-fold (OR 1.5, P=0.037, 95% CI: 1.45-10.34). No association existed for neck calcification (P=0.071). Technical success, adjunctive procedures, perioperative characteristics and outcomes were comparable in friendly and hostile PNAs. CONCLUSIONS: PNA hostility is more likely in AAA with diameter >55 mm but with the use of newer generation endografts this did not influence the short- and mid-term EVAR outcomes. Longer follow-up is needed for a more definite conclusion.

Novel methods for the mechanical characterization of patches used in carotid artery repair.

Carotid endarterectomy (CEA) is one of the approaches available for the treatment of carotid artery disease, with carotid patch angioplasty the pertinent technique mostly preferred by vascular surgeons. This technique entails an arteriotomy succeeded by closure with a textile, polymer or biological tissue patch. In this work, we propose microbuckling and microindentation as novel methodologies for acquiring the mechanical properties of patches used in carotid artery repair. Regarding microbuckling, the patch is loaded by a sensitive dynamometer at one end and its motion is recorded, at three different levels of axial deformation: δ/ℓ = 0.1, 0.3 and 0.5 (in the post-buckling regime). The corresponding experimental loads are recorded, as well. Following pertinent closed-from equations, various material metrics are obtained, such as the Young's modulus of elasticity and the so-called frictional couple of the material. Regarding microindentation, the material's hardness number is measured with the aid of a durometer. Similar to microbuckling, indentation analytical expressions allow for the determination of key material properties, such as the modulus of elasticity, indentation forces and depths. Where possible, we perform microtension to verify acquired results. Results demonstrate that measured properties may vary substantially for materials which are of the same type, due to variations of the material microstructure, as observed with optical and scanning electron microscopes (SEM). Several commercial patches were tested in this work. To shortly present the main results, the microbuckling technique furnished (for the Young's modulus) 40.17 MPa for the B/Braun Aesculap cardiovascular patch and 71.49 MPa for the Vasutek Terumo, while the microindentation technique, for bovine patches, provided 6.356 MPa for the Xeno Sure and 4.701 MPa for the Vascu-Guard. A test type recommendation is provided, relating the type of the patch material to the method more plausible in each case, in order to achieve better measurement accuracy. Results of this study can contribute in establishing guidelines and criteria determining material selection in CEA.

Systematic review of follow-up compliance after endovascular abdominal aortic aneurysm repair.

INTRODUCTION: Lifelong surveillance after endovascular aortic aneurysm repair (EVAR) is recommended to monitor the effectiveness and durability of the treatment. The aim of this study was to assess patients' compliance with the follow-up imaging protocol, the presence of any factors associated with compliance and the potential influence of imaging-protocol adherence on outcomes. EVIDENCE ACQUISITION: MEDLINE, EMBASE, and Cochrane Central databases and key references were searched. EVIDENCE SYNTHESIS: One multicenter observational study (registry) and nine retrospective studies were identified reporting on EVAR surveillance compliance. The studies included 36,119 patients with mean age of 76±3.1 years under mean follow-up ranging from 25 to 73 months. Most of them were males (51-89%), white (51-97.7%) and the majority of them were living over 100 miles from the treatment center. The data were too heterogeneous to perform a meta-analysis. Incomplete follow-up and complete loss of follow-up were ranging from 15% to 65% and 22% to 56%, respectively. Advanced age, symptomatic or ruptured aneurysm, history of chronic diseases, and social-economic factors were associated with poor follow-up compliance. Five studies suggested that complete follow-up did not offer any survival benefit, while only one study suggested that incomplete follow-up was associated with higher fatal complication rates. CONCLUSIONS: Patients' compliance with follow-up protocol after EVAR is about 50%. Several factors have been associated with this poor compliance, however there is lack of solid evidence to show that this poor compliance results in worse outcomes. Prospective studies focusing on follow-up adherence are needed in order to evaluate its impact on the outcomes.

Double fixation for abdominal aortic aneurysm repair using AFX body and Endurant proximal aortic cuff: mid-term results.

Our goal was to evaluate the use of an AFX main body combined with an Endurant proximal aortic cuff to treat selected patients with an abdominal aortic aneurysm (AAA) associated with anatomical challenges, such as a small distal aortic diameter and a hostile aortic neck. A retrospective analysis of prospectively collected data from 2 vascular institutions identified 14 elective patients with an AAA (all men, 73.5 ± 5.1 years) treated with the AFX main body combined with an Endurant proximal aortic cuff. Patients had a small distal aortic diameter (median 19 mm) and a short or angulated proximal aortic neck (median length 20 mm, range 9-26 mm, median angulation 41.5°, range 23-80°). Six patients (42.9%) had an aortic neck that did not meet the indications for use of the AFX proximal aortic cuff. Primary technical success was achieved in all patients with no 30-day device-related complications or deaths. During a median follow-up period of 13 months (range 6-28 months), no re-intervention was needed. The diameter of the aneurysmal sac decreased from 57.6 ± 5.6 mm preoperatively to 50.4 ± 4.9 mm (P < 0.001) postoperatively. There were no aneurysm-related deaths or ruptures. No migration, disconnection or type I or III endoleak was observed. In 5 of the 6 patients, the initial type II endoleak spontaneously resolved during follow-up, whereas that in the remaining patient persisted without any change in the diameter of the aneurysmal sac. In patients with complex AAA anatomical configurations combining a hostile aortic neck and a narrow aortic bifurcation, the use of an AFX main body combined with an Endurant proximal aortic cuff seems to be feasible with favourable mid-term results.

Patterns in the management of superficial vein thrombosis.

Objective To highlight current practice patterns in management of superficial vein thrombosis. Methods An electronic survey was conducted using the mailing lists of the Mediterranean League of Angiology and Vascular Surgery and European Venous Forum regarding superficial vein thrombosis diagnosis, investigation, and treatment. Results The response rate was 41% (175/430) and the majority of the participants were vascular surgeons practicing in a hospital. More experienced physicians considered superficial vein thrombosis as a medical issue of moderate seriousness and performed duplex ultrasound for confirmation of diagnosis. Elastic stockings were recommended by 87% of the physicians, while 57% prescribed nonsteroidal anti-inflammatory drugs. Eighty six percent advised anticoagulation, although a large disparity was shown regarding regime, dose, and duration. Thrombophilia test was regularly suggested by 19% of the physicians. Ligation of the saphenofemoral junction was the treatment of choice by those who suggested intervention in the acute phase of superficial vein thrombosis. Conclusions A great disparity exists in the management of superficial vein thrombosis. Current guidelines have not been adopted by physicians; more focused training is needed for those involved in the management of venous diseases.

Renal Function Impairment in Patients Undergoing Elective EVAR vs. Elective Open Repair During Follow up Period: A Systematic Review of the Literature.

BACKGROUND: Endovascular (EVAR) or open surgical (OSR) repair are current treatment options for abdominal aortic aneurysm (AAA). OBJECTIVE: To produce a systematic review comparing the impact of these 2 treatment options on renal function during mid- and long term follow up. METHODS: The MEDLINE, EMBASE and Cochrane databases and key references were searched. RESULTS: Six studies were included from 2000 to 2016, (4 retrospective and 2 RCT studies) reporting on 2,102 patients (54%; 1096 EVAR, 46%; 1006 OSR). The mean age in EVAR group ranged from 69.4 to 73.8 years (91% males), and in OSR group from 68 to 73.6 years (91% males). The data were too heterogeneous to perform a meta-analysis. All studies used GFR (Glomerular Filtration Rate) or estimated GFR (eGFR) to record renal function. The commonest risk factors were the presence of hypertension (77.5%), hyperlipidaemia (48.3%), coronary artery disease (42%) and smoking (37.8%). During follow up, new events of renal impairment (increase >20% in GFR) in EVAR patients and in OSR patients were 58 (5.3%) and 52 (5.2%), respectively. The mean GFR was decreased during follow up period in both types of the procedure. CONCLUSION: There is lack of definitive evidence to prove the superiority of OSR over EVAR regarding renal function in the post-operative follow up period. It appears that renal impairment may occur after both interventions. Further prospective research is needed to clarify the issue.

Hybrid procedures for chronic lower limb ischemia: what determines the outcome?

BACKGROUND: To report the long term outcome of hybrid (combined open and endovascular) procedures for the management of multisegmental chronic peripheral arterial disease. METHODS: A retrospective analysis from a single center during the period 2009-2013. Patency rates, survival and limb salvage were the primary outcomes. Univariate and multivariate analyses were used to assess the association with various factors. RESULTS: A total of 132 patients (116 males) with mean age of 69±1.4 years, were treated. The technical and hemodynamic success rates were 94% and 97.7% respectively. The primary and assisted primary patency rates in 36 months were 69.7% and 94.7%, respectively. The Hazard Ratio for primary and assisted primary patency failure was 1.94 (95% CI: 1.07-3.51, P=0.029) and 5.55 (95% CI: 1.15-26.79, P=0.033) times higher in diabetic patients, respectively. Limb salvage rate in 36 months was 87.9%. Rutherford category (P=0.046) and previous ipsilateral reconstruction (P=0.011) were the only factors associated with limb loss. CONCLUSIONS: Hybrid procedures are associated with good long term outcomes in the treatment of multisegmental chronic peripheral arterial disease. Diabetes mellitus remains a determinant of worse outcome, while the severity of the disease and previous ipsilateral revascularization are associated with poorer limb salvage.

Factors Associated With Ulcer Healing and Quality of Life in Patients With Diabetic Foot Ulcer.

A prospective nonrandomized cohort study on consecutive diabetic patients with foot ulcer was undertaken to assess the factors associated with the healing process or limb salvage and evaluate the impact of their treatment on their quality of life. Quality of life was evaluated using Diabetic Foot Ulcer Scale-Short Form (DFS-SF) questionnaire before and after treatment. A total of 103 diabetic patients with ulcer (mean age 69.7 ± 9.6 years, 77% male) were treated and followed up for 12 months. Ulcer healing, minor amputation, and major amputation rates were 41%, 41%, and 18%, respectively, while the mortality rate was 18%. Ulcer healing was associated with University of Texas wound grade 1 and the Study of Infections in Diabetic feet comparing Efficacy, Safety and Tolerability of Ertapenem versus Piperacillin/Tazobactam trial's diabetic foot infection wound score. Limb loss was associated with nonpalpable popliteal artery, longer in-hospital stay, and delay until referral. Quality of life was improved in all domains of DFS-SF ( P < .0001) throughout the cohort of our patients regardless of their outcome, and no outcome (healing, minor amputation, or major amputation) was superior to other. Significant improvement was observed in all domains of hygiene self-management after consultation during the follow-up period.

Acute limb ischemia and anticoagulation in patients with history of atrial fibrillation.

BACKGROUND: Atrial fibrillation (AF) is the commonest source of arterial embolization causing acute limb ischemia (ALI). The aim of this study was to assess the adherence of anticoagulation in AF patients and the treatment of underdiagnosed AF patients, presenting with ALI in our service and to evaluate the risk factors associated with morbidity and mortality. METHODS: A retrospective analysis of prospectively collected data was carried out from 115 limbs of 112 consecutive patients presenting with ALI of AF origin from 2008 until 2012 to a tertiary vascular service. RESULTS: The mean transfer time to hospital was 12±8.5 h. On admission, only half of the patients were aware of having AF and only 67% of those patients were receiving oral anticoagulants at the time of their admission. Nearly all patients who were on Vitamin K Antagonists (VKA) had sub-therapeutic levels preoperatively on admission (92%). The 30-day postoperative mortality and morbidity rates were 1.7% and 47% respectively. The lower limb amputation rate was 4.4% and was only associated with diabetes mellitus (DM) (P=0.009553). Reversible renal impairment was correlated with increased creatinine phosphokinase (CPK) blood levels on admission (P=0.038). CONCLUSIONS: A considerable number of patients with AF might still remain without proper anticoagulation. DM increases the risk of lower limb loss after ALI. Development of renal impairment after thromboembolectomy for ALI is more likely in the presence of elevated CPK blood levels on admission.

The association of simple renal cysts with abdominal aortic aneurysms and their impact on renal function after endovascular aneurysm repair.

We validated the association of simple renal cysts with abdominal aortic aneurysm and other cardiovascular factors and assessed simple renal cysts' impact on renal function before and after endovascular abdominal aortic aneurysm repair. A retrospective analysis of prospectively collected data was conducted. Computed tomography angiograms of 100 consecutive male patients with abdominal aortic aneurysm who underwent endovascular abdominal aortic aneurysm repair (Group 1) were reviewed and compared with 100 computed tomography angiogram of aged-matched male patients without abdominal aortic aneurysm (Group 2). Patients' demographic data, risk factors, abdominal aortic aneurysm diameter, the presence of simple renal cyst and laboratory tests were recorded. No difference was observed between the two groups in respect to other cardiovascular risk factors except hyperlipidemia with higher prevalence in Group 1 (p < 0.05). Presence of simple renal cysts was independently associated with age (p < 0.05) and abdominal aortic aneurysm (p = 0.0157). There was no correlation between simple renal cysts and abdominal aortic aneurysm size or pre-operative creatinine and urea levels. No difference was observed in post-operative creatinine and urea levels either immediately after endovascular abdominal aortic aneurysm repair or in 12-month follow-up. In male patients, the presence of simple renal cysts is associated with abdominal aortic aneurysm and is increasing with age. However, their presence is neither associated with impaired renal function pre-endovascular abdominal aortic aneurysm repair and post-endovascular abdominal aortic aneurysm repair nor after 12-month follow-up.

Effectiveness of intravenous ilomedin infusion and smoking cessation in the treatment of acutely symptomatic Buerger disease.

We assessed the effectiveness of iloprost treatment in the management of symptomatic Buerger disease (BD) and assessed smoking cessation compliance, based on a single-center experience. Thirteen patients with BD were treated with sessions of intravenous (IV) Ilomedin infusion. At 1-year follow-up, pain status alteration, number of analgesics required, ankle-brachial index (ABI) change, compliance with supervised smoking cessation, and amputation-free rate were recorded. The pain status improved considerably according to a visual analog scale, the number of analgesics required was significantly reduced, and all patients improved their pain-free walking distance, the ABI, and their self-reported quality of life. Only 2 patients required minor amputations. Combination of IV Ilomedin infusion, supervised smoking cessation, and a specific follow-up protocol may lead to improvement in pain-free walking distance, pain status, quality of life, and substantial reduction in amputation risk.

Combined coronary artery bypass grafting and open abdominal aortic aneurysm repair is a reasonable treatment approach: a systematic review.

We reviewed the literature for studies investigating the outcomes of combined 1-stage coronary artery bypass grafting (CABG) and abdominal aortic aneurysm (AAA) open repair (OR) procedures. An electronic search of the English literature was conducted using the PubMed, EMBASE, and Cochrane databases. Age, coronary heart disease severity, AAA size, mean duration from CABG to AAA OR procedures, details of each procedure, mortality, and morbidity rates were analyzed. Between 1994 and 2012, 12 studies (256 patients) with 1-stage treatment fulfilled the inclusion criteria and were analyzed. There were 20 early (30 days) deaths, accounting for a 30-day mortality rate of 7.8%. The early morbidity was 53% (136 of 256). One-stage treatment when necessary can be undertaken with acceptable mortality and reasonable morbidity rates considering the complexity of both the operations. Nowadays, endovascular AAA repair is preferred over OR. The outcomes of combined cardiac surgery and endovascular AAA repair have not been extensively evaluated.