The Use of the Off-the-Shelf Inner Branch E-nside Endograft for the Treatment of Elective and Emergent Complex Aortic Aneurysms-A Single-Center Experience.

BACKGROUND: The aim of this single-center study was to evaluate the early results of the off-the-shelf inner branch E-nside endograft in the treatment of complex aortic aneurysms and thoracoabdominal aortic aneurysms. METHODS: We performed a retrospective analysis of a prospectively maintained database of all patients treated with the E-nside endograft at our institution during the years 2021-2023. Parameters evaluated were technical success, early major adverse events, target vessel patency, and the presence of endoleaks. RESULTS: In total 16 patients underwent treatment with the E-nside endograft. Six additional patients were evaluated for the device but were excluded due to anatomical considerations. Mean age was 71 (range 59-84) and 14 (88%) were males. Mean aneurysm diameter was 66 mm (range 54-85). Aneurysms treated included thoracoabdominal in 9 (56%), juxtarenal aneurysms in 5 (31%), postdissection aneurysm in 1 (6%) and a type 1A endoleak after a failed endovascular aneurysm repair in 1 (6%). Five of the treated aneurysms were symptomatic. A total of 58 side branches were placed into target visceral arteries. Mean operative time was 190 min (range 150-360). Technical success was achieved in 15/16 of the patients (94%). At 30 days, 1 perioperative mortality and 3 major adverse events occurred, 2 of them branch related. CONCLUSIONS: The E-nside endograft is a feasible option for the treatment of a broad spectrum of aortic pathologies. As it is an off-the-shelf device, it can be used selectively in elective and emergent settings with acceptable 30-day mortality and morbidity. Further follow-up is required to determine the durability of this treatment option and patency of side branches.

Intraoperative calf blood pressure measurements for the detection of early lower extremity ischemia following endovascular aneurysm repair.

BACKGROUND: Access vessel complications during endovascular aneurysm repair (EVAR) remain a concern and has been reported to occur in 3-10% of cases. The purpose of this study is to report our experience with intraoperative, non-invasive calf blood pressure (BP) measurements and ankle brachial indexes (ABIs) before and immediately following EVAR, in evaluating the perfusion of the lower extremities and detecting early lower extremity ischemia (LEI). METHODS: We performed a retrospective review of all consecutive patients who underwent EVAR at our institution between the years 2019 and 2021. All patients had blood pressure cuffs placed on their calves prior to the procedure. Calf BP measurements and ABIs were obtained prior to and immediately after the surgery. Based on the BP measurements, patients were categorized into two groups. Group 1: patients with unchanged ABIs at the end of the procedure. Group 2: patients who experienced a decrease in ABIs at the end of the procedure (no BP obtained or decrease of ABI >0.3 from preoperative measurement). Patients in group 2 underwent exploration of the access vessel. Based on these, the positive and negative predictive values of the study were calculated. RESULTS: During the study period we performed 113 EVAR procedures for abdominal, thoracic, and thoracoabdominal aortic aneurysms, in which 226 femoral arteries were accessed. Mean age was 71 years and 88% were males. In 219 (97%) of the limbs, there was no change in calf BP measurements and ABIs immediately after the procedure, when compared to the preoperative measurements, and none suffered a decrease in follow up ABIs. In 7 limbs (3%), there was a decrease in the calf BP (group 2), and all underwent exploration of the femoral artery. In 5 of these, a pathology was found within the artery. The positive predictive value of the intraoperative calf BP measurement was 71%. The negative predictive value of the study was 100%. CONCLUSION: Intraoperative calf BP and ABIs is a simple method to assess the lower limb perfusion and detect LEI following EVAR. The exam is particularly accurate in ruling out LEI as it has a very high negative predictive value. However, an abnormal measurement does not necessarily confirm LEI.

Oxygen uptake kinetics during exercise reveal central and peripheral limitation in patients with iliofemoral venous obstruction.

OBJECTIVE: Pulmonary oxygen uptake (V˙O2) kinetics measured during the initiation of exercise mirror energetic transition during daily activity. The aim of this study was to elucidate the pathophysiological mechanisms of exercise limitation of patients with chronic iliofemoral vein obstruction after deep vein thrombosis by measuring V˙O2 kinetics compared with patients with peripheral arterial disease (PAD) and healthy individuals. METHODS: Eleven patients with iliofemoral vein obstruction (7 men; age, 20-65 years), seven patients with PAD (all men; age 44-60 years) and eight healthy participants (5 men; age 28-58 years) were studied. Participants performed upper and lower limb symptom-limited cardiopulmonary exercise tests on cycle ergometers; and four repeat lower limb tests at a constant work rate corresponding with 90% of the gas exchange threshold for determining V˙O2 kinetics. RESULTS: Phase I V˙O2 amplitude in the constant work rate tests (percent increase over resting V˙O2), representing the initial surge in cardiac output caused by the emptying of leg veins, was 59 ± 19% in the iliofemoral vein obstruction group, 73 ± 22% in PAD, and 85 ± 26% in healthy participants (P = .055 for iliofemoral vein obstruction vs healthy). Phase II V˙O2 kinetics, which largely reflect the kinetics of O2 consumption in the exercising muscles, were slower in iliofemoral vein obstruction (tau = 42 ± 6 seconds), and PAD (tau = 49 ± 19 seconds), compared with healthy participants (23 ± 4 seconds; P < .01). CONCLUSIONS: Slow phase II V˙O2 kinetics reflect a slow onset of muscular aerobic metabolism in both iliofemoral vein obstruction and PAD. The low amplitude phase I of V˙O2 kinetics observed in iliofemoral vein obstruction suggests a damped cardiodynamic phase, consistent with decreased venous return from the obstructed veins. These abnormalities of V˙O2 kinetics may contribute to exercise intolerance in iliofemoral vein obstruction and PAD.

Short-term outcomes of inner branches for endovascular repair of complex abdominal and thoracoabdominal aortic aneurysms.

OBJECTIVES: To report our early experience using endografts with inner branches for the treatment of complex abdominal aortic aneurysms and thoracoabdominal aortic aneurysms (TAAAs). METHODS: A retrospective analysis of all patients treated in our institution for complex abdominal aortic aneurysms and TAAAs with custom-made stent grafts consisting of one or more inner branches. Data collected included patients demographics, aortic aneurysm morphology, stent grafts features, perioperative morbidity and mortality and short-term reintervention and mortality rates. RESULTS: Twenty-seven patients (18 males, mean age 70 ± 7.1) were included. Indications for surgery included TAAAs (12, 41%) juxtarenal abdominal aortic aneurysms (10, 37%), type 1A endoleaks (4, 15%) and paraanastamotic aneurysms (1, 4%). A total of 90 inner branches were used. Twenty-one (78%) of the stent grafts consisted only of inner branches and six (22%) had a combination of inner branches with either fenestrations or outer branches. Technical success was achieved in 26/27 (96%) of the patients. There was one perioperative mortality. Six patients suffered from major perioperative adverse events. Mean follow-up was seven months (range 1-23). During the follow-up period, four patients (15%) required reinterventions. Branch-related reinterventions were performed in two (7%) patients. No occlusions of inner branches occurred during the follow-up. CONCLUSIONS: Inner branches in branched endovascular aneurysm repairs offer a feasible option for the treatment of complex abdominal aortic aneurysms and TAAAs. The procedures can be completed with high technical success and with acceptable short-term branch-related reintervention rates. Further follow-up is required to determine the long-term durability of this technology.

The Jailed Coiling Technique for the Treatment of Penetrating Ulcers and Saccular Aneurysms of the Aortic Arch.

OBJECTIVE: To evaluate the technical success and short-term outcome of patients with penetrating aortic ulcers (PAUs) and saccular aneurysms (SAs) of the aortic arch treated with the jailed coiling technique. METHODS: A retrospective review of 9 patients (mean age 70 years, 9 males) treated for PAUs and SAs of the aortic arch between 2018 and 2019 at our institution. Treatment included thoracic endovascular aneurysm repair (TEVAR) with a short (1cm) proximal landing zone, followed by coiling of aneurysm through a jailed extraluminal catheter. RESULTS: All 9 patients underwent TEVAR followed by jailed coiling of the lumen of the aneurysms. Debranching of supra-aortic vessels was performed in 4 patients in order to create a proximal landing zone of at least 10 mm. Technical success was achieved in all cases. Coils were placed accurately within the aneurysm lumen in all patients. No distal embolization occurred. One patient expired in the perioperative period from a cardiac event. No patient developed spinal cord ischemia or stroke in the perioperative period. Mean follow-up was 10 months (range 3-18). On follow-up imaging, complete thrombosis of the aneurysm lumen was seen in all patients. None experienced enlargement of ulcer dimensions and none required reintervention. CONCLUSION: PAUs and SAs of the aortic arch with a very short landing zone can be treated successfully by jailed coiling of the aneurysm and TEVAR. The procedure is technically feasible and can be performed with minimal morbidity. Long-term durability of the repair needs to be determined.

Vascular complications after transcatheter aortic valve implantation and their association with mortality reevaluated by the valve academic research consortium definitions.

Vascular complications (VC) after transcatheter aortic valve implantation (TAVI) are reported using various criteria and several access site approaches. We aimed to describe them in a solely percutaneous transfemoral TAVI approach and their association with survival using both the updated Valve Academic Research Consortium (VARC)-2 criteria and the former VARC-1 criteria. From March 2009 to September 2013, 403 consecutive patients at a mean age (±SD) of 83 ± 6 years underwent percutaneous transfemoral TAVI. VC were defined by both VARC-1 and VARC-2 criteria and analyzed separately. Cox proportional hazard ratio models for all-cause mortality were adjusted separately as defined by each criteria. VARC-1-defined and VARC-2-defined VC occurred in 71 (18%) and 78 (19%) patients, respectively, with 15 (4%) and 33 (8%) defined as major VC. The difference in frequency of major and minor VC was mainly driven by VARC-2 implementation of major bleeding events. With either VARC definition, patients with minor VC had similar mortality and complications rates as those patients without VC. In multivariate analyses, referenced to patients with minor or no VC, only VARC-1-defined major VC were significantly associated with increased mortality (hazard ratio 3.52; confidence interval 1.5 to 8.4; p = 0.005), whereas VARC-2-defined major VC were found to be only marginally significant (hazard ratio 1.9; confidence interval 0.9 to 3.9; p = 0.08). In conclusion, the implementation of the VARC-2 criteria resulted in a higher rate of reported major VC after TAVI compared with VARC-1 criteria, mainly by the inclusion of major bleeding events and a reduced association with patient mortality.

Kidney transplantation from pediatric donors: size-match-based allocation.

Use of kidneys from pediatric donors has been associated with worse outcome. We review our 20-yr experience using pediatric kidneys as single grafts in children and adult recipients. Charts review of 29 recipients, transplanted between 1986 and 2005, who received a graft from a donor

Actual colonic perforation in virtual colonoscopy: report of a case.

Computed tomography colonography, also termed virtual colonoscopy, is a new imaging method to investigate the colon, which may be a potential alternative to the conventional endoscopic colonoscopy in some cases. The high safety profile of this imaging method was considered as an additional advantage of this procedure. A case of colonic perforation in computed tomography colonography is presented, highlighting a potential risk related to this procedure. It is assumed that perforation was the result of overinflation of air into an obstructed colon caused by a lesion at the rectosigmoid junction. Thus, it is suggested that in such cases, air insufflation should be gradual, thereby minimizing the risk of perforation.

Small bowel obstruction from a dislodged feeding tube.

Elderly nursing home patients may suffer from inadequate oral nutritional intake for a variety of reasons. In some of them, nutritional status cannot be maintained without the use of enteral feeding. Nasogastric tube feeding is associated with significant patient discomfort, and may lead to significant complications. Thus, in those who require long-term enteral tube feeding, a gastrostomy tube may be necessary. Although surgical insertion may occasionally be required, percutaneous insertion with upper endoscopy assistance is usually safe and feasible. This case represents an unusual complication of such a gastrostomy tube, which draws attention to the need for appropriate care of these tubes.