Choices of Stent and Cerebral Protection in the Ongoing ACST-2 Trial: A Descriptive Study.

OBJECTIVE/BACKGROUND: Several plaque and lesion characteristics have been associated with an increased risk for procedural stroke during or shortly after carotid artery stenting (CAS). While technical advancements in stent design and cerebral protection devices (CPD) may help reduce the procedural stroke risk, and anatomy remains important, tailoring stenting procedures according to plaque and lesion characteristics might be a useful strategy in reducing stroke associated with CAS. In this descriptive report of the ongoing Asymptomatic Carotid Surgery Trial-2 (ACST-2), it was assessed whether choice for stent and use or type of CPD was influenced by plaque and lesion characteristics. METHODS: Trial patients who underwent CAS between 2008 and 2015 were included in this study. Chi-square statistics were used to study the effects of plaque echolucency, ipsilateral preocclusive disease (90-99%), and contralateral high-grade stenosis (>50%) or occlusion of the carotid artery on interventionalists' choice for stent and CPD. Differences in treatment preference between specialties were also analysed. RESULTS: In this study, 831 patients from 88 ACST-2 centres were included. Almost all procedures were performed by either interventional radiologists (50%) or vascular surgeons (45%). Plaque echolucency, ipsilateral preocclusive disease (90-99%), and significant contralateral stenosis (>50%) or occlusion did not affect the choice of stent or either the use of cerebral protection and type of CPD employed (i.e., filter/flow reversal). Vascular surgeons used a CPD significantly more often than interventional radiologists (98.6% vs. 76.3%; p < .001), but this choice did not appear to be dependent on patient characteristics. CONCLUSION: In ACST-2, plaque characteristics and severity of stenosis did not primarily determine interventionalists' choice of stent or use or type of CPD, suggesting that other factors, such as vascular anatomy or personal and centre preference, may be more important. Stent and CPD use was highly heterogeneous among participating European centres.

Immediate surgery for acute internal carotid artery dissection and thrombosis during filter deployment prior to stenting: a case report.

Carotid artery stenting (CAS) is a validated option in the treatment of selected extracranial carotid artery stenosis. Carotid artery dissection during CAS is a rare but potentially devastating complication. We report a case of acute dissection and thrombosis of the left internal carotid artery during filter tip wire engaging maneuvers, complicated by intraoperative complete blindness of the left eye. Immediate conversion to carotid endarterectomy was performed under general anesthesia with electroencephalographic monitoring. The patient was discharged home symptomless and remains asymptomatic eight months after the operation, with normal left internal carotid patency and fully recovered eyesight. In conclusion, the management of acute carotid occlusion during CAS requires emergent evaluation and definitive endovascular or open surgical repair to minimize neurologic morbidity. We advocate that all endovascular procedures are carried out in a well-established surgical environment.

Extracranial internal carotid artery stenting in Moya-Moya syndrome: a case report.

A 58-year-old Caucasian lady presented for severe left internal carotid artery (ICA) stenosis. Two months before she was operated for right carotid endarterectomy (CEA) in another Institution, complicated with internal carotid artery thrombosis and development of transient hemiplegia and aphasia. Postoperative selective DSA showed the development of an abnormal basal meshwork of collateral vessels with typical evidence for moyamoya disease. Preoperative workup in our Institution included cerebral MRI witch showed two ischemic right frontal and parietal lesions. The patient underwent successful stenting of the left ICA. This is the first report of extracranial ICA stenting in a patient with moyamoya syndrome.

Immediate conversion to CAS after neurological intolerance at cross-clamping test during CEA: a preliminary experience.

AIM: The aim of this preliminary study is to evaluate the feasibility and efficacy of CAS as treatment option to endarterectomy when carotid shunt cannot be used safely. METHODS: The medical records concerning 469 carotid stenosis treated between January 2006 and December 2009 were retrospectively reviewed, focusing on cross-clamp intolerance during CEA. Patients with cross-clamping intolerance were divided in two groups. Group 1: those that concluded the open procedure with the use of a shunt, and Group 2: those who experience immediate brain intolerance and coma and were immediately converted to an endovascular procedure. Mortality and neurological adverse event rate were compared between shunted CEA and cross-clamping intolerant cases converted into CAS. The secondary end-point was long-term survival. RESULTS: Carotid cross-clamp intolerance occurred in 30 cases (8.7%). CEA with Pruitt-Inahara's shunt was performed in 17 cases with a perioperative neurological adverse event rate of 23.5%. In 13 cases limitations to shunting due to quick onset of coma and/or an unfavorable anatomy were encountered. In these 13 cases the open intervention was immediately converted into endovascular procedure. Technical success was achieved in all the converted to CAS cases (100%), with a perioperative neurological adverse event rate of 7.7% (P=0.35 between the two groups). No significant difference emerges comparing patient's survival between the cases CONCLUSION: Nevertheless, the small dimension of this survey, immediate conversion to CAS resulted feasible with a lower risk of neurological adverse events if compared to CEA with shunt, and could be considered as an alternative to CEA when carotid shunt cannot be used safely.

Percutaneous transluminal angioplasty improves glucose control and quality of life in patients with critical limb ischemia.

AIM: To evaluate the benefit of endovascular peripheral revascularization on glucose control in patients with chronic limb ischemia. METHODS AND RESULTS: Over a 12 month period, 61 patients (41 male, range 49-88 years of age) presenting with critical limb ischemia (CLI) were treated according to the Trans Atlantic Inter Society Consensus (TASC II) guidelines. After discharge, all patients were asked to measure their glucose level three times daily, and glycated hemoglobin was checked monthly up to 12 months, as well as to fill a questionnaire to assess their Quality of Life (QoL). The revascularization procedure was successful in 90% of cases. Glycemic control and glycated hemoglobin in 22 diabetic patients subgroup were significantly improved after the treatment and remained stable over the follow-up period. There was a significant improvement in QoL that increased steadily from the operation and to reach a plateau after six months. CONCLUSIONS: Peripheral percutaneous angioplasty in subjects with CLI significantly improves glycemic control and ameliorates QoL. Revascularization positively effects also long-term diabetes control as well as QoL.

Endovascular management of symptomatic cerebral malperfusion due to carotid dissection after type A aortic dissection repair.

PURPOSE: Type A acute aortic dissection is a surgical emergency, and supra-aortic trunk involvement may be complicated by stroke in 6% to 20% of cases. A 66-year-old Caucasian female patient underwent a composite repair of the ascending aorta for type A aortic dissection. Postoperative period was complicated by episodes of "drop attack." Doppler ultrasound of supra-aortic trunks revealed an intimal flap occluding right internal carotid artery. TECHNIQUE: Multiple stenting was performed from carotid bifurcation to internal carotid artery in order to exclude the dissection intimal flap. After endovascular procedure physiatrist considered that motor functional improvement was better than expected, and we support that endovascular resolution of carotid malperfusion led to a better outcome. CONCLUSION: According to other experience, endovascular procedure resulted as a safe and effective way. Moreover, ultrasound monitoring of supra-aortic trunks in postoperative period is recommended.

Endovascular treatment of penetrating aortic ulcers: mid-term results.

OBJECTIVES: The aim of this study was to evaluate mid-term results of endovascular treatment of penetrating aortic ulcers. METHODS: Between February 2000 and November 2006, 18 consecutive patients underwent endovascular treatment of the descending thoracic aorta (N=16) and abdominal infrarenal aorta (N=2) for penetrating aortic ulcer, in a single University Hospital. Data were prospectively collected and retrospectively analyzed. Mean follow-up was 41 months (range 4 to 77 months). RESULTS: Technical success was achieved in all patients. No perioperative deaths occurred. No conversion to open repair or secondary procedures were required. Two patients died in the follow-up period for reasons not related to penetrating aortic ulcers. One type II endoleak was observed. It was still present, unchanged, twelve months after the procedure. CONCLUSION: Endovascular treatment of penetrating aortic ulcers of the descending thoracic and infrarenal aorta were safe and effective in the mid-term in this small series of patients.

Inflammatory abdominal aortic aneurysms. A 20-year experience.

AIM: The aim of the study was to report a 20-year single Institution experience, with the early and late outcomes of surgical treatment of inflammatory abdominal aortic aneurysms. METHODS: In a 20-year period, 2 275 consecutive patients underwent elective surgical repair for non-rupture abdominal aortic aneurysm. Fifty-two patients (2.3%) were classified as inflammatory abdominal aortic aneurysms. Early and late outcomes were analyzed. RESULTS: One patient died in the perioperative period, giving a mortality rate of 1.92%. One patient died from a pseudoaneurysm rupture 7 months after operation. Three patients developed an aortic pseudoaneurysm in the follow-up period (mean 12.1 years, range 1-20 years) and underwent a redo operation. CONCLUSION: Overall surgical outcome of these patients, in terms of short-term and long-term is good. A high rate of pseudoaneurysm formation was observed.

Case report of adventitial cystic disease of the popliteal artery presented with the ''dog-leg'' sign.

Adventitial cystic disease of the popliteal artery constitutes an infrequent cause of claudication in non-atherosclerotic young or middle-aged population. Here, we report the case of a 43-year-old female with adventitial cystic disease of the popliteal artery causing left lower leg claudication, detected by duplex scanning. The angio-CT showed the "dog-leg" sign, typical of the aneurysm of the popliteal artery. Surgery was performed through the posterior approach. The cyst and the affected segment of the artery were successfully excised and replaced with an autogenous saphenous vein graft. In 1 year follow-up the graft is patent and the patient is completely asymptomatic.

Duplex scanning on admission prevents unnecessary carotid endarterectomies.

AIM: This retrospective single Institution study, aims to evaluate the performance of duplex scanning on admission of patients with carotid artery disease to avoid unnecessary carotid endarterectomies. METHODS: From 1 January 1997 until 31 Decem-ber 2004, 1 504 patients were admitted to our Institution to undergo carotid endarterectomy. A duplex scan on admission was performed in all of them. RESULTS: A total of 1 369 from these patients (91%) underwent surgery, while 135 (9%) were dismissed because there was no indication for surgical treatment. They were put in conservative treatment and periodic duplex control appointments. CONCLUSIONS: In 9% of the patients, unnecessary carotid endarterectomy was avoided.

Retrograde aorto-mesenteric by-pass grafting as treatment option of recurrent chronic mesenteric ischemia after thrombosed superior mesenteric artery stenting. Report of a case.

We report a case of early stent failure in a patient with chronic mesenteric ischemia and its treatment with a retrograde aorto-mesenteric by-pass. The patient was initially treated with angioplasty and stenting. Seven months after the procedure complete thrombosis of the stent was achieved. A retrograde aorto-mesenteric by-pass was performed. After two years the patient remains asymptomatic and color Duplex scan confirm the patency of the graft.

[Intestinal and colonic ischaemia in the surgery of subdiaphragmatic aorta]. / Ischemia intestinale e colite ischemica nella chirurgia dell'aorta sottodiaframmatica.

Ischemic colitis resulting in colonic infarction after aortic reconstruction is a highly lethal complication. The etiology and pathogenesis of this condition demonstrate that in many instances it may be prevented. Early recognition, particularly of the transmural ischemic injury is essential. Numerous techniques used during surgery for assessing the adequacy of colonic perfusion have been evaluated and found to be inaccurate in terms of predicting colonic ischemia. The purpose of this study is to assess the main monitoring technique for prediction of ischemic colitis during aortic surgery as: colonic mesenteric Doppler signal, inferior mesenteric arteries stump pressure, sigmoidal intramucosal pH and measurement of mucosal capillary haemoglobin oxygen saturation by reflectance spectrophotometry. A 15-year experience with 1912 patients undergoing abdominal aortic reconstruction was reviewed to determined both the incidence of intestinal ischemia and the clinical anatomic, and technical factors associated with this complication of aortic surgery

Mid-term results after endovascular repair of abdominal aortic aneurysms: a four-year experience.

OBJECTIVES: The purpose of this retrospective, single-institution study is to describe a 4-year experience of examining early and late clinical outcomes after endovascular repair of abdominal aortic aneurysm (AAA). MATERIALS AND METHODS: Between October 1998 and January 2003, 455 patients were submitted for AAA treatment, of whom 269 underwent open repair and 186 were treated with an endovascular procedure. All endovascular-treated patients underwent preoperative arteriography, contrast enhanced CT scanning or spiral-CT to define the morphological characteristics of the aneurysm, including precise diameter and length measurements. RESULTS: Technical success was achieved in 182 (98%) of the endovascular procedures, as intraoperative conversions to open repair and/or aborted procedures occurred in four patients. The perioperative (30-day) mortality rate was 1% (two patients). During the follow-up period (9-60 months) CT, duplex ultrasound scanning and plain abdominal X-ray evaluation were performed at 3, 6, 12 months, and annually thereafter. Type I endoleak occurred in 12 patients (6.6%), required a further endovascular procedure (11) or late conversion to open repair (1). Type II endoleak occurred in five patients (3%). CONCLUSIONS: In our clinical experience the endovascular repair of AAA is a safe and effective technique with good mid-term results in patients at standard and high risk.

Endovascular treatment of hepatic artery aneurysm in a patient with Ehlers-Danlos syndrome. Case report.

Ehlers-Danlos syndrome (EDS) is a rare, variably inherited disorder affecting connective tissue. Patients with EDS often develop aneurysms of the thoracic and abdominal aorta as well as the visceral arteries. We report our experience with an elective endovascular exclusion of an hepatic artery aneurysm in a 26-year-old female patient with EDS type IV. A balloon-expandable 4x26 mm stent-graft was placed in the common hepatic artery, excluding the aneurysm. The follow-up at the 2, 6 and 18 months showed the patency of the common hepatic artery, the absence of endo-leak and the right location of the stent-graft. In EDS patients, the endovascular treatment could be preferable to open surgery because of the minimum trauma.

Midterm experience with the endovascular treatment of isolated iliac aneurysms.

AIM: The aim of this retrospective, single institution study was to describe our 4-year experience with the endovascular repair of isolated iliac artery aneurysms. METHODS: Between May 1997 and June 2001, 16 patients (15 males; mean age 64+/-9 years), were treated with covered stent grafts. Twelve of the endovascular procedures were performed under epidural and 4 under local anaesthesia. The percutaneous approach was employed in 13 cases and the femoral artery had to be exposed in 3 cases that demanded simultaneous revascularization of the peripheral circulation (n=2) or required a 16 F sheath to employ a Baxter Lifepath stent graft (n=1). The mean size of the iliac aneurysms was 4.5 cm (range 3.5 to 5.2 cm). Four aneurysms involved the hypogastric ostium in absence of any distal neck. RESULTS: All the patients underwent initially successful endovascular treatment of isolated iliac aneurysms and were followed from 3 to 52 months (mean 18 months). No procedural deaths and no acute or late graft thrombosis occurred. The perioperative complications included 1 dissection of the external iliac artery that required a further endovacular procedure and 1 case of endovascular leak fed to the hypogastric artery. A CT scan 4 months later showed spontaneous thrombosis of aneurysm and no further leakage. Two patients had undergone combinated femoro-popliteal arterial bypass. CONCLUSION: In our early clinical experience the use of self-expandable covered stent graft successful treated isolated iliac artery aneurysms. Endovascular repair is a safe and effective technique with good midterm results in patients at standard and high risk.