A case of gastroduodenal artery aneurysm in a HIV-positive patient treated by combined percutaneous thrombin injection and endovascular coil embolization.

First described in 1989, HIV-related aneurysms have been rarely reported. Considered atypical if compared to classic atherosclerotic diseases, they show no preferred location and frequently involve young patients with no other risk factors for atherosclerosis but with an impaired immune system. They are probably related to an auto-immune damage inside the aortic wall associated with a necrotizing perivasculitis. Visceral artery aneurysms are rare and life-threatening diseases; the superior mesenteric and gastro-duodenal and pancreatic vessels are rarely involved. The advantages related to the endovascular approach to these aneurysms seems to be even more effective in immuno-impaired patients (i.e. HIV+). We report a case of a young patient affected by a HIV-related gastroduodenal artery aneurysm which was treated with a combined percutaneous and endovascular approach.

Percutaneous treatment of complete chronic occlusions of the superficial femoral artery.

PURPOSE: This study was done to evaluate the mid-and long-term patency rates of complete (from the origin to Hunter's duct) chronic occlusions of the superficial femoral artery (SFA) treated by angioplasty and/or stenting. MATERIALS AND METHODS: From February 2002 to March 2005, 21 patients with complete occlusion of the SFA and good distal runoff (two or three patent vessels) were treated with endovascular recanalisation. All patients had severe claudication or critical limb ischaemia. In all cases, recanalisation was performed with a contralateral approach by percutaneous transluminal angioplasty (PTA), with stenting only when PTA provided unsatisfactory results (due to elastic recoil and complications such as dissection). In the case of calcified occlusions and when the true lumen of the SFA could not be crossed, subintimal angioplasty was performed. Follow-up was done at 6 and 12 months and annually thereafter (range 6-55 months, mean 23 months) with clinical evaluation and colour-Doppler ultrasound. RESULTS: Immediate technical success was achieved in all cases (100%), with post-procedural angiography demonstrating complete recanalisation of the SFA. Two distal embolisation (9.5%) occurred, both treated successfully by local thrombolysis. Primary patency rates at 6, 12, 24, 32 and 44 months were 93.3%, 69.2%, 72.7%, 62.5% and 40%, respectively; secondary patency rates at 6, 12 and 24 months were 100%, 84.6% and 81.8%, respectively. CONCLUSIONS: Percutaneous treatment of complete chronic occlusions of the SFA showed good mid-and long-term primary patency rates, with few periprocedural complications. Re-occlusions can be treated by a percutaneous technique, which ensures a good secondary patency rate.

Extracranial-intracranial bypass for giant aneurysms and complex vascular lesions: a clinical series of 10 patients.

AIM: The purpose of this clinical study is to evaluate the preventive bypass indications, the kind of bypass to use, and the timing of postoperative internal carotid artery (ICA) occlusion in the treatment of complex aneurysms. METHODS: This study enrolled 10 patients suffering from complex aneurysms treated using several kind of extra-intracranial bypass on the basis of preoperative careful assessment of cerebrovascular flow. This assessment is based on the balloon test occlusion (BTO), from which three different conditions emerge. According to the Department of Neurosurgery these three different conditions require three different kinds of bypass: in case of depleted flow a short STA-MCA bypass is necessary, in case of intermediate flow a long arterial graft bypass is required, whereas in case of high flow a long venous graft bypass is mandatory. RESULTS: Bypass patency was found in six out of seven patients who underwent surgery for giant ICA aneurysms, as well as in other patients. One of the patients died for a septic shock, another had a neck hematoma that required surgical evacuation. At mean follow-up no further neurological deficits were found. CONCLUSION: The severe complications due to the combined approaches can be reduced thanks to the indications obtained by BTO concerning the kind of bypass to perform and to the timing of the ICA occlusion.

Endovascular treatment for para-anastomotic abdominal aortic and iliac aneurysms following aortic surgery.

AIM: The aim of this study was to report our experience with endovascular repair of anastomotic aneurysms occurring after graft replacement for abdominal aortic aneurysms or aorto-iliac obstructive disease. METHODS: Between January 2000 and April 2006, 19 consecutive male patients (median age 73 years) underwent endovascular repair for 22 anastomotic aneurysms [proximal aortic (n=15), iliac (n=4), concomitant aortic and iliac (n=3)], occurring 3 months to 18 years (mean 8.6 years) after open surgery. Three patients (15.7%) underwent emergency treatment for rupture. No patient had symptoms or positive blood tests for infection of the original graft. Twelve patients were treated with a bifurcated stent-graft, 4 patients with a proximal stent-graft cuff, 2 patients with a tube iliac stent-graft, and 1 patient with a mono-iliac stent-graft. RESULTS: Stent-grafts were successfully deployed in all patients. Procedure-related complications or death were not observed; open conversion was never required. Median hospitalisation was 9 days (range 3-45). During a median follow-up of 16 Euro-months (range, 2-44) all anastomotic aneurysms maintained excluded: 4 patients (21%) died. We observed 1 major complication (5.2%): an iliac branch occlusion occurred 1 month after the procedure, successfully treated with catheter-directed thrombolysis. Overall, survival rates at 6, 12, 18 and 36-months were 92.8%, 84.4%, 72.3%, and 57.8% respectively. CONCLUSION: Our experience confirms that endovascular stent-grafts can be used successfully to exclude anastomotic aortic aneurysms after open surgery. Endovascular repair seems to be effective at mid-term follow-up.

Endovascular treatment of isolated iliac artery aneurysms: 2-year follow-up.

PURPOSE: The aim of this study was to assess the effectiveness of endovascular treatment of isolated iliac artery aneurysms (IAAs). MATERIALS AND METHODS: Between March 1999 and March 2004, 15 isolated IAAs in 13 patients (mean age: 71.8 years) were selected for endovascular repair by means of a covered stent or stent-graft: 12 were in the common iliac artery (2 with the proximal end 12 mm from the aortic bifurcation and 2 involving the distal hypogastric artery), and three were in the external iliac artery. The preoperative study and the follow-up (at 3, 6 and 12 months and yearly thereafter) were performed by computed tomography (CT) angiography. RESULTS: Primary technical success was obtained in all cases, without periprocedural complications. Two patients died within 3 months and were not considered for follow-up. Follow-up (mean duration: 25 months, range: 6-60 months) in the remaining 11 patients, affected by 13 aneurysms, showed aneurysm exclusion in nine cases and progressive shrinkage of the aneurysmal sac in four cases, whereas in the other five, the size of the aneurysm remained unchanged. In a patient with bilateral IAA, bilateral proximal endoleaks were observed after 2 years, and the patient was treated with a bifurcated aortic stent-graft. In another patient with a large aneurysm, a left aortofemoral bypass became necessary after 2 months because of stent-graft dislodgement. In another patient, an endoleak from the hypogastric artery occurred after 2 years but was not treated. CONCLUSIONS: Endovascular treatment of isolated IAA is a feasible procedure that is less invasive than surgery and yields excellent short-and midterm results. However, a longer follow-up and larger patient series are needed to verify the long-term efficacy of this form of treatment.

Endovascular repair of a pseudo-aneurysm of the common femoral artery after revision total hip arthroplasty.

Vascular injuries with acute arterial haemorrhage are rare but the infrequency of these complications may make their diagnosis and treatment challenging for surgeons unfamiliar with their management. In the past, surgery or coil embolisation has been used to treat these lesions; we describe the case of a pseudo-aneurysm of the common femoral artery developed during a total hip arthroplasty, promptly managed with an endovascular stent graft.

Mid-term results of endovascular reconstruction for aorto-iliac obstructive disease.

AIM: Aorto-iliac obstructive disease has been traditionally treated with endarterectomy and/or a surgical bypass graft. Kissing-stents technique has been proposed to reconstruct the aorto-iliac bifurcation for complex aorto-iliac lesions. METHODS: We report 43 patients with complex aorto-iliac occlusions managed with endovascular repair. Between March 1999 and October 2005, a total of 43 patients with a mean age of 66+/-10 years underwent endovascular treatment for aorto-iliac obstructive disease. Lesions were classified C (n=34) and D (n=9), accordingly to the Trans-Atlantic Inter-Society Consensus (TASC) classification. All endovascular interventions were performed in the theatre under regional anesthesia. Predilation with kissing-balloons angioplasty was usually performed; the bifurcation was then eventually reconstructed using bilateral stents placed with the kissing technique. Clinical examination and duplex scans or computed tomography-angiography (CT-A) were performed at discharge and 1, 6, and 12 months after the procedure, with yearly studies thereafter. RESULTS: Kissing-stents technique was selectively used in 30 cases (69.7%); the remainder cases were treated with kissing-balloons. Major complications occurred in 2 patients (4.6%). Overall, mean hospitalization was 4.1+/-2.8 days (median 3 days). Mean follow-up was 32.4 months (range 1-84 months; median 36 months). During the follow-up, 2 patients (4.6%) died. Duplex and/or CT-A examination detected 4 re-occlusions. Primary patency rates at 12, 24, and 60 months were 92%, 85.7%, and 80.7%, respectively; overall secondary patency rate was 40/43 patients. CONCLUSIONS: We consider this approach most appropriate for patients deemed at high operative risk for conventional repair or for those who refuse surgery.

Management and endovascular treatment of symptomatic abdominal aortic aneurysms.

PURPOSE: Our aim is to verify the feasibility and effectiveness of endovascular treatment for symptomatic abdominal aortic aneurysms (AAAs) in urgencies and emergencies. MATERIALS AND METHODS: Over the past 51 months, we treated 38 symptomatic AAAs with endovascular exclusion. In 23 haemodynamically stable patients, computed tomography (CT) angiography was performed before treatment, and AAA exclusion was carried out as an urgent procedure; 15 patients with haemorrhagic shock were examined by ultrasound (US) only in the emergency room whereas the procedure was carried out in emergency and planned using angiography. Time from presentation to treatment was 100 min on average (range: 50-150 min). We used 27 Excluder (Gore) and 11 Zenith (Cook) stentgrafts. The follow-up was performed with CT angiography after 1, 3, 6 and 12 months and yearly thereafter. RESULTS: The immediate technical success rate was 100%, and the perioperative mortality rate was 10.5%. At follow-up completed in 34 patients (range: 1-48 months, mean: 19.2), we observed five endoleaks (14%) (four type 2: two thrombosed spontaneously and two were under observation at the time of writing; one type 3, treated with stent-graft extension) and one occlusion of a stentgraft leg (treated by femorofemoral bypass). CONCLUSIONS: Endovascular treatment of AAAs is a good therapeutic alternative even in urgency and emergency conditions where correct planning ensures technical results comparable with those obtained under elective conditions.

Endovascular treatment of steno-occlusions of the infrarenal abdominal aorta.

PURPOSE: Our aim is to report our experience in the endovascular treatment of steno-occlusions of the infrarenal abdominal aorta. MATERIALS AND METHODS: We selected 19 patients (mean age 66.3 years, range 45-80): five with complete occlusion of the infrarenal aorta and both common iliac arteries (CIAs), four of which were associated with occlusion of the external iliac arteries (EIAs); three with complete occlusion and three with severe stenosis of the distal aorta with occlusion or stenosis of the CIAs and EIAs; and eight with focal severe stenosis of the infrarenal aorta. All patients were treated with direct stenting. RESULTS: Immediate technical success was 94.7% (18/19 cases). We observed two cases of distal embolism treated with thrombolysis, one case of mild renal failure and one case of transient angina abdominis. During the follow-up (mean 19.6 months; range 6-48), 2/18 (11.1%) occlusions of an iliac stent occurred 1 and 3 months after the procedure (treated with local intra-arterial thrombolysis). The primary patency rate was 88.8% and the secondary patency rate was 100%. CONCLUSIONS: Direct stenting is a feasible and safe option for the treatment of infrarenal abdominal aortic steno-occlusions, especially in patients at high surgical risk, with good early and late clinical results.

Endovascular repair for thoracic aortic arch aneurysms.

AIM: The aim of this study was to report our experience with total and subtotal endovascular stent-grafting combined with aortic arch branch surgical revascularization for thoracic aortic arch aneurysms in high-risk patients. METHODS: From December 2000 to June 2005, among 38 patients treated with thoracic stent-grafts in our department, 10 patients (9 men; mean age 71+/-6 years) at high risk for open repair were candidates for endovascular repair and/or aortic arch branch extra-anatomical reconstruction due to inadequate proximal landing zones. The left subclavian artery was over-stented 6 cases for zone 2 aneurysms, and partial or total arch stent-grafting with simultaneous revascularization of the arch branches was performed in 4 cases for zones 0-1 aneurysms. RESULTS: Primary technical success rate was 100%. In-hospital mortality rate was 10%. Neither paraplegia, nor acute renal failure were recorded. Immediate or late surgical conversion was never required. One type 1b was successfully treated with additional stent-graft and 2 type-2 endoleaks were sealed by coil embolization. Mean follow-up was 21-months (range 3-48 months); overall, survival rate at 12, 26, and 36 months was 90%, 60%, and 30%, respectively. CONCLUSIONS: Endovascular repair for thoracic aortic arch aneurysms is feasible. However, our experience suggests stent-grafting is not free of risk, and long-term and larger follow-up is required.

Mid-term experience with the ALN retrievable inferior vena cava filter.

OBJECTIVE: To report the mid-term results of 63 patients who received a new commercially-available retrievable vena cava filter, ALN. METHODS: Between January 2001 and October 2005, 63 patients (mean age 65 +/- 15 years) underwent placement of ALN filters. Filter removal was performed when anti-thrombotic prophylaxis was considered unnecessary or when the patient could safely resume full anticoagulant therapy. RESULTS: Thirty-five patients (55%) had ilio-femoral venous thrombosis and 28 patients (45%) had ilio-caval thrombosis. Overall, 49% had pulmonary embolism. Technical success for filter insertion was 100%, without any complications. None of the procedures aborted or was converted due to technical difficulties. After a median follow-up of 21-months (range 1-48, median 18), there were no cases of pulmonary embolism or vena cava thrombosis. Two patients died of a cause unrelated to deep venous thrombosis during the follow-up period, without clinical evidence of pulmonary embolism or filter-associated complications. No device migration was observed. There were 20 (31.7%) retrieval attempts: in 16 cases filters were retrieved successfully, but 4 cases were aborted. The mean implantation period of the retrieved filter was 179 days (range 53-370). CONCLUSION: Our results confirm the clinical efficacy of the ALN filter for preventing potentially fatal pulmonary embolism whilst implanted and in absence of post-insertion complications, even when left in place indefinitely.

Intentional coverage of the left subclavian artery during endovascular stent graft repair for thoracic aortic disease.

BACKGROUND: Surgical revascularization of the left subclavian artery (LSA) has been performed to warrant arm perfusion and to prevent paraplegia during thoracic stent graft (SG) procedures. We retrospectively investigated the outcome after intentional occlusion of the left subclavian artery during SG repair for thoracic aortic diseases. METHODS: From December 2000 to June 2005, 11 patients (mean age, 57 +/- 19 years) with a short (<1 cm) proximal aspect of a thoracic aortic lesion underwent intentional LSA coverage to expand the proximal landing zone for SG fixation. Three patients were treated in the emergency setting. We did not perform a prophylactic revascularization of the LSA prior to SG implantation. A preliminary balloon occlusion test of the LSA was not performed in this series. The SG was positioned so that its covering was immediately distal to the left common carotid artery. RESULTS: SG implantation was technically successful in all patients. Intraoperative mortality was not observed; no patient suffered any impairment of left carotid artery flow. Aortography after SG implantation showed no direct flow in the LSA and refilling of the LSA via the ipsilateral vertebral artery. After the intervention, mean systolic pressure in the left arm decreased by 38 +/- 17 mmHg. The stented length of the aorta was 171 +/- 73 (median, 150). During hospitalization, no patient showed any signs of left arm malperfusion. Paraplegia was not observed. One patient developed transient ischemic attack. During a mean follow-up of 19 +/- 8 months (range, 3-36), all patients were completely asymptomatic and had no functional deficit or temperature differential between arms. No leakage was detected. CONCLUSION: Intentional LSA occlusion seems to be well tolerated. Prophylactic surgical maneuvers may be relegated to an elective measure after an endovascular aortic intervention when intolerable signs or symptoms of ischemia occur.

Endovascular repair of traumatic injuries of the subclavian and axillary arteries.

INTRODUCTION: Injury to the subclavian and axillary arteries is uncommon. Standard surgical techniques require wide exposure and dissection in traumatised areas which is often challenging and associated with significant morbidity, and mortality ranges from 5 to 30%. We report our experience with the endovascular treatment of these injuries. METHODS: We retrospectively studied patients with blunt or penetrating (including iatrogenic) injuries to the subclavian or axillary artery between January 2000 and September 2004. Demographic data, mechanism of injury, concomitant injuries, angiographic findings, and treatment method and outcome were recorded. Nine patients with injury to the subclavian or axillary artery were seen at our institution during the study. Two patients underwent interventions, seven patients had lesions amenable to endovascular repair. RESULTS: Immediate success was obtained in all procedures (100%). All patients continue to have patent grafts with a follow-up ranging from 3 to 48 months (mean 22.6 months). The procedure-related complication was the need for a brachial artery pseudoaneurismectomy at the site of device insertion in one patient (14.7%). None of the patient developed a device fracture. CONCLUSION: Endovascular stent-grafts offer an effective, less invasive alternative to standard techniques in treating traumatic arterial lesions, resulting in shorter procedure time and less blood loss than previously reported.

Ruptured abdominal aortic aneurysm: endovascular treatment.

BACKGROUND: This report describes our preliminary experience in endovascular management of 25 ruptured abdominal aortic aneurysms (rAAAs). METHODS: In the past 3 years we treated 46 patients who had rAAA, and 25 (54.3%) were treated with an endovascular approach. Patients' mean age was 76 +/- 9 years. The diagnosis was confirmed by computed tomographic angiography in 23 patients (92%). Mean aneurysm diameter was 73 +/- 17 mm. We used an infrarenal bifurcated device in 17 patients (68%), a suprarenal bifurcated in four patients (16%), and an aortomonoiliac graft in four patients (16%). Overall, nine patients (36%) required intensive care. Every patient underwent radiologic follow-up according to the Eurostar register, with concomitant evaluation of the D-dimer level (cut-off <200 microg/L) as a biological marker for endoleaks. RESULTS: The primary technical success rate was 100%. Overall in-hospital mortality rate was 20%. Mean hospitalization was 7 days (range, 3-30), and mean follow-up was 7 months. One occlusion (4%) of the iliac limb and two type II endoleaks (8%) occurred. The mean D-dimer level in type I endoleak was 1045 microg/L (range, 459-2021). CONCLUSIONS: In our experience, endovascular management of rAAA is feasible and safe and produces better results than conventional surgery, provided the morphology is suitable and the procedure is carried out by an experienced endovascular team.

Hybrid treatment for thoracic and thoracoabdominal aortic aneurysms in patients unfit for open conventional repair.

PURPOSE: To describe a technique combining endovascular and conventional surgery for the treatment of distal aortic arch and thoracoabdominal aortic aneurysms. MATERIAL AND METHODS: In the last two years, we used hybrid approach to treat six patients with distal aortic arch or thoracoabdominal aortic aneurysms unfit for open conventional repair owing poor cardio-respiratory function. RESULTS: The primary technical success rate was 100%. Intraoperative mortality rate was 0; conversion to open conventional repair was never required. Mean operation time and blood loss averaged 256 minutes and 1233 ml, respectively. Neurological complications were not observed. Overall, two patients died postoperatively. During a mean 17-month follow-up, two minor type II endoleak occurred and were successfully managed with coil embolization. All stent-grafts and conventional bypasses were patent, and no stent-graft-related complication was observed. CONCLUSION: Our initial experience attests the feasibility and potential attractive alternative of hybrid treatment for distal arch and thoracoabdominal aortic aneurysms.

[The evaluation of the efficacy of drapes and gowns of nonwoven fabric versus drapes and gowns of cotton in reducing the incidence of postoperative wound infections]. / Valutazione dell'efficacia di teli e camici in tessuto non tessuto verso teli e camici in cotone nel ridurre l'incidenza delle infezioni postoperatorie della ferita.

The importance of the preparation of an operative field which will guarantee satisfactory conditions of asepsis during the entire operation is an indispensible premise for controlling the development of postoperative wound infections. This paper compared the efficacy of disposable clothes and gowns in TNT FABRIC 450* in relation to cotton gowns in reducing the incidence of postoperative wound infections. Cotton items were used for 25 subjects out of a group of 50 operated patients and nonwoven fabric (TNT FABRIC 450*) items were used for the other 25. Thorough bacteriological tests were performed in each patient before, during and after the operation. On the basis of the duration of the operation, it was observed that TNF FABRIC 450* was as efficacious as cotton in controlling postoperative infections in those operations with a short or medium duration; it offered greater protection in lengthy operations, with a higher risk of endogenous and exogenous contamination. It was also observed that disposable items were indispensable in patients treated with radioactive materials and offered greater safety in seropositive patients.