Increasing use of open conversion for late complications after endovascular aortic aneurysm repair.

OBJECTIVE: Open procedures are often required for late complications after endovascular aneurysm repair (EVAR). Our aim was to describe the indications for open interventions and their postoperative outcomes and to specifically examine our experience with limited conversions in which problem endoleaks are targeted without endograft explantation. METHODS: We reviewed patients from 2002 to 2017 who underwent any surgical abdominal aortic operation after a previous EVAR. Baseline characteristics, preoperative imaging, procedural details, and postoperative outcomes were reviewed. The primary end point was 30-day mortality. RESULTS: There were 102 patients who underwent open conversion 3.8 ± 3.1 years after EVAR. The numbers increased significantly in recent years, with 18 cases performed in 2016; 48.5% of patients had undergone 1.9 ± 1.0 prior endovascular interventions. The indication for surgical conversion was an endoleak in 85 patients and infection in 15. One patient had a limb occlusion and another a proximal aneurysm. The 30-day mortality was 6.2% in 65 patients treated electively for endoleak but higher in 20 ruptures (40.0%) and 15 infections (40.0%). In a multivariate logistic regression model, independent predictors of 30-day mortality were rupture (odds ratio [OR], 6.70; 95% confidence interval [CI], 1.75-25.60; P = .005), endograft infection (OR, 8.48; 95% CI, 1.99-36.20; P = .004), and use of a supraceliac clamp (OR, 4.80; 95% CI, 1.47-15.66; P = .009). Transient acute kidney injury (12.8%) and prolonged intubation (11.8%) were the most common postoperative complications. In 65 patients treated for endoleak without rupture, 37 underwent endograft explantation, whereas 28 had a graft-preserving intervention (branch vessel ligation for type II endoleak in 26, external banding of the aneurysm neck for type IA endoleak in 8). Mortality was 8.1% when the endograft was explanted and 3.6% when it was not (P = .63). During 3.0 ± 3.5 years of follow-up, there was one reintervention after endograft explantation (for rupture secondary to type IB endoleak) and two reinterventions after graft preservation (for a new type IA endoleak and a new type II endoleak). Survival was 87.4% at 1 year and 70.9% at 5 years. CONCLUSIONS: Open conversion is playing an increasing role in the management of late EVAR complications. Endoleaks treated electively by open conversion are reasonably safe and show good midterm durability, even with graft-preserving interventions that avoid endograft explantation.

Peroneal bypass versus endovascular peroneal intervention for critical limb ischemia.

OBJECTIVE: The peroneal artery is a well-established target for bypass in patients with critical limb ischemia (CLI). The objective of this study was to evaluate the outcomes of peroneal artery revascularization in terms of wound healing and limb salvage in patients with CLI. METHODS: Patients presenting between 2006 and 2013 with CLI (Rutherford 4-6) and isolated peroneal runoff were included in the study. They were divided into patients who underwent bypass to the peroneal artery and those who underwent endovascular peroneal artery intervention. Demographics, comorbidities, and follow-up data were recorded. Wounds were classified by Wound, Ischemia, foot Infection (WIfI) score. The primary outcome was wound healing; secondary outcomes included mortality, major amputation, and patency. RESULTS: There were 200 limbs with peroneal bypass and 138 limbs with endovascular peroneal intervention included, with mean follow-up of 24.0 ± 26.3 and 14.5 ± 19.1 months, respectively (P = .0001). The two groups were comparable in comorbidities, with the exception of the endovascular group's having more patients with cardiac and renal disease and diabetes mellitus but fewer patients with smoking history. Based on WIfI criteria, ischemia scores were worse in bypass patients, but wound and foot infection scores were worse in endovascular patients. Perioperatively, bypass patients had higher rates of myocardial infarction (4.5% vs 0%; P = .012) and incisional complications (13.0% vs 4.4%; P = .008). At 12 months, the bypass group compared with the endovascular group had better primary patency (47.9% vs 23.4%; P = .002) and primary assisted patency (63.6% vs 42.2%; P = .003) and a trend toward better secondary patency (74.2% vs 63.5%; P = .11). There were no differences in the rate of wound healing (52.6% vs 37.7% at 1 year; P = .09) or freedom from major amputation (81.5% vs 74.7% at 1 year; P = .37). In a multivariate analysis, neuropathy was associated with improved wound healing, whereas WIfI wound score, cancer, chronic renal insufficiency, and smoking were associated with decreased wound healing. Treatment modality was not a significant predictor (P = .15). CONCLUSIONS: Endovascular peroneal artery intervention results in poorer primary and primary assisted patency rates than surgical bypass to the peroneal artery but provides similar wound healing and limb salvage rates with a lower rate of complications. In appropriately selected patients, endovascular intervention to treat the peroneal artery is a low-risk intervention that may be sufficient to heal ischemic foot wounds.

Heel Wounds Predict Mortality but Not Amputation after Infrapopliteal Revascularization.

BACKGROUND: Ischemic heel ulcerations are generally thought to carry a poor prognosis for limb salvage. We hypothesized that patients undergoing infrapopliteal revascularization for heel wounds, either bypass or endovascular intervention, would have lower wound healing rates and amputation-free survival (AFS) than patients with forefoot wounds. METHODS: A retrospective chart review was performed on patients who presented between 2006 and 2013 to our institution with ischemic foot wounds and infrapopliteal arterial disease and underwent either pedal bypass or endovascular tibial artery intervention. Data were collected on patient demographics, comorbidities, wound characteristics, procedural details, and postoperative outcomes then analyzed by initial wound classification. The primary outcome was major amputation or death. RESULTS: Three hundred ninety-eight limbs underwent treatment for foot wounds; accurate wound data were available in 380 cases. There were 101 bypasses and 279 endovascular interventions, with mean follow-up of 24.6 and 19.9 months, respectively (P = 0.02). Heel wounds comprised 12.1% of the total with the remainder being forefoot wounds; there was no difference in treatment modality by wound type (P = 0.94). Of 46 heel wounds, 5 (10.9%) had clinical or radiographic evidence of calcaneal osteomyelitis. Patients with heel wounds were more likely to have diabetes mellitus (DM) (P = 0.03) and renal insufficiency (P = 0.004). 43.1% of wounds healed within 1 year, with no difference by wound location (P = 0.30). Major amputation rate at 1 year was 17.8%, with no difference by wound location (P = 0.81) or treatment type (P = 0.33). One- and 3-year AFS was 66.2% and 44.0% for forefoot wounds and 45.7% and 17.6% for heel wounds, respectively (P = 0.001). In a multivariate analysis, heel wounds and endovascular intervention were both predictors of death; however, there was significant interaction such that endovascular intervention was associated with higher mortality in patients with forefoot wounds (hazard ratio 2.25, P < 0.001) but not those with heel wounds (hazard ratio 0.67, P = 0.31). CONCLUSIONS: Patients presenting with heel ulceration who undergo infrapopliteal revascularization are prone to higher mortality despite equivalent rates of amputation and wound healing and regardless of treatment modality. These patients may benefit from an endovascular-first strategy.

Nitric oxide donors for peripheral artery disease.

Current management of peripheral arterial disease involves risk factor modification and revascularisation, but many patients are still left with debilitating symptoms. Therefore, new treatment strategies are needed. The importance of nitric oxide, and its role in regulating endothelial function, is well-established. Altering the nitric oxide pathway has been extensively studied as a means of treating vascular disease, including peripheral arterial disease. Statins and ACE inhibitors have been shown to enhance endogenous nitric oxide and improve intermittent claudication symptoms. Studies using l-arginine have produced differing results, for reasons for yet fully understood. A greater understanding of the nitric oxide pathway, and its enzymatic control, has generated more potential therapeutic targets to alter NO levels.

Prior Endovascular Intervention Is Not Detrimental to Pedal Bypasses for Ischemic Wounds.

BACKGROUND: Endovascular strategies are often preferred for revascularization of ischemic foot wounds secondary to infrapopliteal disease because of the less invasive technique and faster recovery. Bypass is typically reserved for failures or lesions not amenable to balloon angioplasty. However, the effects of an endovascular-first approach on subsequent bypass grafts are largely unknown. This study evaluates the effects of prior endovascular tibial interventions (PTIs) on successive bypasses to pedal targets. METHODS: Patients who presented with ischemic tissue loss and tibial arterial occlusive disease to University of Pittsburgh Medical Center between 2006 and 2013 and underwent a surgical bypass to pedal arteries were included in this study. A retrospective chart review was conducted to obtain patient demographics, past medical history, extent of disease, prior tibial endovascular interventions, the treatment intervention, subsequent interventions, wound healing status, limb salvage, and patient survival. The primary outcome was primary patency of the pedal bypass graft. RESULTS: From 122 eligible patients, 27 had a PTI, whereas 95 had no prior endovascular tibial intervention (nPTI) in the treatment of ischemic pedal wounds with mean follow-up of 24.5 and 20.5 months, respectively (P = 0.36). The 2 groups were largely similar in terms of demographics, comorbidities, wound size, and degree of ischemia. Runoff scores between the 2 groups were also comparable (5.0 ± 1.6 for PTI and 4.8 ± 1.9 for nPTI, P = 0.59). The plantar artery was a more common target vessel in the PTI group, whereas the posterior tibial artery was targeted more often in the nPTI group (P = 0.04). At 12 months, those with a PTI exhibited a shorter primary patency (34.8% vs. 60.2%, P = 0.04). In a multivariate model, PTI was a significant risk factor for primary patency loss (hazard ratio 2.51, P = 0.004). Primary assisted patency and secondary patency were similar between the 2 groups. Wound healing was improved in those patients who had a prior endovascular intervention with 63.8% healed at 1 year compared with only 34.8% of those without intervention (P = 0.01). Amputation-free survival was similar (P = 0.68), as was survival alone (P = 0.50). CONCLUSIONS: Despite a decrease in primary patency, pedal bypass was not otherwise negatively affected by a PTI. Similar primary assisted patency, secondary patency, wound healing, and survival between the 2 patient populations indicate that an endovascular-first approach is a feasible treatment strategy to achieve similar clinical outcomes in the management of ischemic foot wounds.

Bypass versus endovascular intervention for healing ischemic foot wounds secondary to tibial arterial disease.

OBJECTIVE: Pedal (inframalleolar) bypass is a long-standing therapy for tibial arterial disease in patients with ischemic tissue loss. Endovascular tibial intervention is an appealing alternative with lower risks of perioperative mortality or complications. Our objective was to compare the effectiveness of these two treatment modalities with respect to patency and limb-related clinical outcomes. METHODS: We performed a retrospective chart review of patients presenting between 2006 and 2013 with ischemic foot wounds and infrapopliteal arterial disease who underwent a revascularization procedure (either open surgical bypass to an inframalleolar target or endovascular tibial intervention). Data were collected on baseline demographics and comorbidities, procedural details, and postprocedure outcomes. The primary outcome was successful healing of the index wound, with mortality, major amputation, and patency assessed as secondary outcomes. RESULTS: We identified 417 patients who met our eligibility criteria; 105 underwent surgical bypass and 312 underwent endovascular intervention, with mean follow-up of 25.0 and 20.2 months, respectively (P = .08). The endovascular patients were older at baseline (P = .009), with higher rates of hyperlipidemia (P = .02), prior cerebrovascular accidents (P = .04), and smoking history (P = .04). Within 30 days postoperatively, there was no difference in mortality (P = .31), but bypass patients had longer hospital length of stay (P < .0001), higher rate of discharge to nursing facility (P < .001), and higher rates of myocardial infarctions (P = .03) and wound complications (P < .001). At 6 months, the rate of wound healing was 22.4% in the bypass group compared with 29.0% in the endovascular group (P = .02). At 1 year, survival was higher after bypass (86.2% vs 70.4%; P < .0001), but freedom from major amputation was similar (84.9% vs 82.8%; P = .42). Primary patency (53.1% vs 38.2%; P = .002) and primary assisted patency (76.6% vs 51.7%; P < .0001) were higher in the bypass group, but there was no difference in secondary patency (77.3% vs 73.8%; P = .13). CONCLUSIONS: Endovascular tibial intervention is associated with poorer primary patency but similar secondary patency and wound healing rates compared with the "gold standard" of surgical bypass to a pedal target. In patients with tibial arterial disease, endovascular intervention should be considered a lower risk alternative to pedal bypass that provides similar clinical outcomes.

Outcomes of iliac vein stents after pregnancy.

OBJECTIVE: Stenting is the first-line treatment for obstructive iliocaval lesions when intervention is required. The aim of the study was to evaluate iliocaval stent patency during and after pregnancy in women of reproductive age who became pregnant after stent placement. METHODS: Female patients of reproductive age (18-45 years old) who underwent iliocaval stenting between May 2007 and March 2014 were identified from a three-center prospectively maintained database. Medical records were reviewed for demographics, baseline risk factors, operative data, and clinical follow-up to identify pregnancy and postpartum stent imaging. The primary end point was stent patency. Standard descriptive statistics were used. RESULTS: There were 310 women of reproductive age who received iliocaval stenting; 12 were identified to have had at least one pregnancy after stenting. The mean age was 28 ± 5 years. One patient received thrombolysis and stenting at 14 weeks of pregnancy for deep venous thrombosis (DVT) and May-Thurner syndrome, three for a previous postpartum DVT (2, 4, and 6 weeks postpartum), three for DVT before any pregnancy with a history of factor V Leiden, and the remaining five for unprovoked DVT. All stents were self-expanding with a diameter range of 14 to 16 mm. Mean time from stenting to pregnancy was 23.3 ± 28 months. All patients had patent stents during pregnancy and were prescribed therapeutic low-molecular-weight heparin by their obstetrician. One had asymptomatic left-sided stent compression 1 year after her second delivery, treated with balloon dilation. At average follow-up of 61 ± 56 months, all patients had patent stents with no ultrasound-identified structural damage or thrombosis. CONCLUSIONS: Pregnancy does not negatively affect the outcomes of iliocaval stents after lysis of DVT or May-Thurner syndrome. Iliocaval stenting is not contraindicated in women of reproductive age, although close clinical and ultrasound follow-up is warranted during and after pregnancy.

Serum VEGF and bFGF in patients with inflammatory bowel diseases.

AIM: The role of angiogenesis in inflammatory bowel diseases (IBD) remains controversial. We investigated the role of serum concentration levels of VEGF and bFGF in IBD patients and assessed their potential association to disease activity. PATIENTS AND METHODS: Blood samples were obtained from 40 IBD patients with moderate to severe attack of the disease and 40 healthy controls. VEGF and bFGF serum levels were assessed. C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) were measured as markers of disease activity and correlated to VEGF and bFGF. RESULTS: The demographic characteristics of both patients and controls were homogenous, in regard of age, sex, smoke and concomitant diseases. VEGF serum levels were significantly higher in IBD patients compared to controls (1158.5±845.4 pg/ml vs 464.6±283.1 pg/ml, p<0.001). Serum concentration levels of bFGF did not differ between groups. Linear regression analysis showed no direct association between VEGF or bFGF and CRP or ESR. CONCLUSION: VEGF, but not bFGF, may have a prominent role in patients with IBD, without though direct association to disease activity. KEY WORDS: bFGF, Inflammatory bowel disease, VEGF.

The chimney graft technique for preserving visceral vessels during endovascular treatment of aortic pathologies.

OBJECTIVE: Patients with juxtarenal, pararenal, or thoracoabdominal aneurysms require complex surgical open repair, which is associated with increased mortality and morbidity. The "chimney graft" or "snorkel" technique has evolved as a potential alternative to fenestrated and side-branched endografts. The purpose of this study is to review all published reports on chimney graft (CG) technique involving visceral vessels and investigate the safety and efficacy of the technique. METHODS: Studies were included in the present review if visceral revascularization during endovascular treatment of aortic pathologies was achieved via a CG implantation. Reports on the chimney technique for aortic arch branches revascularization were excluded. A multiple electronic health database search was performed on all articles published until April 2011. RESULTS: The electronic literature search yielded 15 reports that fulfilled the inclusion criteria. A total of 93 patients (81.3% male; mean age, 71.9 ± 0.9 years) were analyzed. In 77.4% of the patients, the CG procedure was applied for the treatment of abdominal aortic aneurysms. Out of the 93 patients, 24.7% were operated on in an urgent setting (symptomatic or ruptured aneurysm). A total of 134 CGs were implanted: 108 to the renal arteries, 20 to the superior mesenteric artery, five to the celiac trunk, and one to the inferior mesenteric artery. In 57 patients, a single CG was deployed; in 32 patients, two CGs; in three patients, three CGs; and in one patient, four CGs were deployed. Ninety-four percent of CGs were directed proximally, whereas 6.0% were directed caudally. Primary technical success was achieved in all patients. A total of 13 patients (14.0%) developed a type I endoleak. Three were detected and treated intraoperatively. Postoperatively, 10 type I endoleaks were revealed, four of which required secondary intervention. During a mean follow-up period of 9.0 ± 1.0 months, 131 of 134 (97.8%) CGs remained patent. Two CGs to the renal arteries and one to the superior mesenteric artery occluded. Postoperatively, 11.8% of patients suffered renal function impairment and 2.1% a myocardial infarction. Ischemic stroke presented in 3.2% of patients. The 30-day in-hospital mortality was 4.3%. CONCLUSIONS: The role of the chimney technique in the management of complex abdominal aortic aneurysms is still unclear. This technique has relatively good results, considering the anatomic limitations of the aortic neck. However, long-term endograft durability and proximal fixation remains a significant concern. Thus, there is a reasonable hesitation to embrace the method for widespread use in the absence of long-term data.

Percutaneous endovascular treatment of aortic aneurysms: clinical evaluation and literature results.

In this study we aimed to evaluate the efficiency of percutaneous endovascular aortic aneurysm repair (p-EVAR). Anatomically selected patients treated with a single 10Fr Perclose Prostar XL vascular closure device (VCD) were examined. Primary success rate and common femoral artery (CFA) open conversion (OC) requirement per sheath size used were recorded. A literature review on p-EVAR results was also performed. One-hundred patients were enrolled. Successful p-EVAR was achieved in 183 of the 196 CFA access sites (93.4%), and was specifically 85.9% and 98.3% for sheaths ≥20Fr and ≤18Fr respectively. There were 13 periprocedural complications (bleeding = 10, arterial dissection and thrombosis = 1, pseudoaneurysm = 2) all leading to OC. Use of ≥20Fr sheaths had significantly higher OC rate (P < .05). Reconstruction was achieved with primary repair (N = 11) and patch angioplasty (N = 2). Mean hospital stay was 1.8 days. The literature review (vascular closure of 2921 CFA access sites) revealed an overall technical success rate of 92.3%. Device related- were more common than patient related-OCs (P < .05). p-EVAR procedures are safe and feasible. Sheath size is a significant predictor of OC rate and more OCs might be expected with very large (≥20Fr) sheath sizes.

Hybrid open endovascular technique for aortic thoracoabdominal pathologies.

BACKGROUND: Many authors using a hybrid debranching strategy for the treatment of thoracoabdominal pathologies have reported disappointing results and the initial enthusiasm for the technique has given way to criticism and ambiguity. The aim of the present meta-analysis study was to assess the safety and efficacy of the technique in patients with thoracoabdominal aortic aneurysms or other aortic pathologies. METHODS AND RESULTS: A multiple electronic search was performed on all articles describing hybrid open endovascular repair. Separate meta-analyses were conducted for technical success, visceral graft patency, spinal cord ischemia symptoms, renal insufficiency, and other complications as well as 30-day/in-hospital mortality. Nineteen publications with a total of 507 patients were analyzed. The pooled estimates for primary technical success and visceral graft patency were 96.2% (95% CI, 93.5%-98.2%) and 96.5% (95% CI, 95.2%-97.8%) respectively. A pooled rate of 7.5% (95% CI, 5.0%-11.0%) for overall spinal cord ischemia symptoms was observed; whereas for irreversible paraplegia the pooled rate was 4.5% (95% CI, 2.5%-7.0%). The pooled estimate for renal failure was 8.8% (95% CI, 3.9%-15.5%). The pooled 30-day/in-hospital mortality rate was 12.8% (95% CI, 8.6%-17.0%). During the mean follow-up period of 34.5 (95% CI, 31.5-37.5) months, a total of 119 endoleaks were identified in 111 patients (22.7%). CONCLUSIONS: The repair of thoracoabdominal pathologies by means of hybrid procedures in patients who are poor surgical candidates is still associated with significant morbidity and mortality rates. Future studies may substantiate whether the technique is amenable to amelioration and improvement.

Endograft accommodation on the aortic bifurcation: an overview of anatomical fixation and implications for long-term stent-graft stability.

In light of the results of randomized trials, it seems that despite the favorable short and midterm outcomes of standard endografts, concern over endograft migration has escalated, as this event will be responsible for almost all late complications in endovascular aneurysm repair (EVAR). Migration forces, both caudal and sideways, depend heavily on blood pressure, inlet diameter, and angulation of the stent-graft, while the bifurcation generates more force than any other segment of the stent-graft. It thus seems that the position of the endograft's flow divider influences force distribution and migration risk. Additionally, due to concomitant ongoing aortic degeneration, postoperative dilatation of the infrarenal aortic neck poses a threat to EVAR patients as soon as the diameter of the infrarenal neck reaches the dimensions of the proximal graft. This review evaluates the significance of endograft accommodation on the aortic bifurcation and cumulative experience of the only endografts utilizing this feature: the Zenith Composite and the Powerlink.

Advances in assessment and management of carotid body tumors.

Evolving technology has the potential to alter the overall management of carotid body tumors (CBTs). We review our 35-year experience emphasizing on novel modalities available in the evaluation and treatment of CBTs. Medical records of 27 CBT patients between 1975 and 2009 were retrospectively reviewed. The study cohort has been arbitrarily divided into two groups: the early years' group A (18 patients, 1975-1998) and the later years' group B (9 patients, 1999-2009). The most common presenting symptom was a painless lateral neck mass (89%). Octreotide scintigraphy and genetic testing were routinely used for group B. In two cases, octreotide scintigraphy was coupled with intraoperative radiolocalization of the lesion. Preoperative embolization was performed in four CBTs. Among group B patients, five were pretreated via a covered stent placement in the external carotid artery (ECA). Twenty-three patients (24 CBTs) were eventually operated upon. One cardiovascular death, one permanent vocal cord paralysis and six transient cranial nerve injuries account for a 4.4% 30-day mortality and a 30.4% morbidity with no significant differences among groups. In conclusion, appropriate use of new techniques in CBT management has improved diagnostic accuracy and early detection without clearly affecting overall outcome in our study cohort.

Retrograde transpopliteal approach of iliofemoral lesions.

PURPOSE: Aim of this study is to present our initial experience with the use of the retrograde popliteal artery access in patients with certain anatomic lesions. METHODS: Between September 2008 and September 2010, 24 patients underwent a transpopliteal retrograde subintimal recanalization. Instead of its usage when antegrade recanalization failed, the "facedown" technique was preferred as a first choice in patients with common femoral artery stenosis or occlusion, proximal lesions of the superficial femoral artery (SFA) with no stump, severe obesity, tandem iliac, and SFA lesions. RESULTS: Technical success was achieved in 91.7% of patients.The complication rate was 12.5%. The primary patency at 6, 12, and 18 months was 86.4%, 65.8%, and 65.8%, respectively. CONCLUSIONS: The retrograde popliteal artery approach can be considered as the primary SFA recanalization strategy in carefully selected patients, with competitive immediate and midterm results.

Current role of biomarkers in carotid disease: a systematic review.

BACKGROUND AND PURPOSE: Accumulating evidence suggests that carotid plaque vulnerability can be used as a determinant of ischemic stroke risk stratification and carotid intervention. Novel markers of high-risk carotid plaque in patients are needed. SUMMARY OF REVIEW: Advances in cellular and molecular pathophysiology, the demand for accurately predicting carotid risk, and choosing the optimal prevention strategy are stimulating great interest in the development of novel surrogate markers. Biomarkers in cardiovascular disease are expected to predict the natural history, clinical outcomes, and the efficacy of disease-modifying interventions. We aimed to review the literature regarding clinical data on novel serum biomarkers related to ischemic cerebrovascular events associated with carotid artery disease. We provide background information on the biomarkers related to all aspects of carotid disease: natural history, carotid intervention strategies for symptomatic and asymptomatic patients, perioperative risk prediction, and their therapeutic implications. CONCLUSION: At present, heterogeneous data support evidence that biological markers can help existing practices to more accurately assess patients at risk for stroke. Randomized-controlled trials for carotid artery disease and carotid intervention, incorporating biomarkers, are needed.

Abdominal aortic endograft proximal collapse resulting in aortic aneurysm rupture.

An 82-year-old man was transferred to our emergency department due to acute abdominal pain. He had undergone an endovascular abdominal aortic aneurysm repair (EVAR) six years ago. An intravenous contrast-enhanced abdominal computed tomography revealed the rupture of the abdominal aortic aneurysm (AAA) with a large retroperitoneal hematoma. A Talent (Medtronic, Santa Rosa, CA, USA) modular bifurcated endoprosthesis had vertically collapsed approximately 7 cm after losing its infrarenal fixation. As a result, it led to the repressurization of the aneurysm sac and rupture. The patient was successfully treated by placing three Talent (Medtronic) aortic cuffs. To our knowledge, this is the first reported case of endograft collapse that has manifested with aortic aneurysm rupture. Although they are gradually declining, considerable rates of complications create the 'Achilles' heel' of endovascular repair of AAAs. A lifelong follow-up strategy for patients treated for AAA with EVAR is essential for the early detection and treatment of complications of the procedure.

Protective effect of NAC preconditioning against ischemia-reperfusion injury in piglet small bowel transplantation: effects on plasma TNF, IL-8, hyaluronic acid, and NO.

BACKGROUND: Ischemia-reperfusion (I/R) injury is one of the main factors affecting the function and structure of small bowel transplantation (SBT), by generation of proinflammatory mediators such as reactive oxygen species, reactive nitrogen species, cytokines, and endotoxin. Experimental data have demonstrated that N-acetylcysteine (NAC) attenuates intestinal I/R injury. The objective of this study was to determine the effect of NAC preconditioning on the SBT-I/R induced inflammatory cascade, with particular focus on TNF, IL-8, hyaluronic acid, and NO. METHODS: Fifteen domestic pigs were used as donors. Fifteen recipient animals were randomly assigned into two groups. Group 1: SBTx (n=7) served as controls and Group 2: SBTx (n=8) served as the experimental group (NAC administration). RESULTS: NAC administration at a continuous 4 h intravenous bolus dose of 200 mg/kg of body weight, starting before initiation of bowel transplantation, resulted in statistically significant (P<0.05) higher plasma levels of NO, and lower plasma levels of hyaluronic acid, TNF-α, IL-8, and LDH compared with those of the control group, at the 360 min time point. CONCLUSIONS: NAC confers a protective role in small bowel transplantation associated, partly, with NO generation and hyaluronic acid, TNF-α and IL-8 amelioration.

Conversion to open repair after endografting for abdominal aortic aneurysm: a review of causes, incidence, results, and surgical techniques of reconstruction.

PURPOSE: To review the incidence, causes, and mortality rates of early and late conversion to open surgery after endovascular aneurysm repair (EVAR) of abdominal aortic aneurysm (AAA). METHODS: A systematic search of the English-language literature from 2002 to 2009 was performed by interrogation of the PubMed, MEDLINE, and EMBASE databases. Studies were included if they: (1) had >100 patients treated with EVAR and (2) provided adequate data to calculate incidence and associated mortality rates. The search yielded 13 articles with sufficient data to analyze early conversion (12,236 patients, 178 conversions) and 15 articles with available data for late conversion (14,298 patients, 279 conversions). RESULTS: The rate of early conversion among the 13 articles reviewed ranged from 0.8% to 5.9%; more recent studies carried lower rates of early conversion. Mortality rates of early conversion varied between 0% and 28.5%. Overall, there were 178 (1.5%) early conversions among the 12,236 AAAs treated with EVAR, with an average mortality of 12.4%. The rates of late conversion ranged from 0.4% to 22%. Of the 14,289 AAA patients undergoing endovascular repair, 279 (1.9%) required late conversion; the mortality rate was 10%. CONCLUSION: Though the incidence is gradually declining, secondary interventions persist as the Achilles' heel of EVAR. A lifelong follow-up strategy for AAA patients treated with EVAR is essential for early detection and treatment of complications of the procedure. Vascular surgeons should be familiar with the complex open conversion procedures.