Prospective Observational Study after Eversion Carotid Endarterectomy with Ultrasound-Guided Deep-Intermediate Cervical Plexus Blockade.

(1) Introduction: The aim was to describe the anesthetic and surgical technique of eversion carotid endarterectomy performed under intermediate-deep cervical block with sedation, and to analyze the intraoperative and postoperative results. (2) Material and Methods: Thirty cases of unilateral eversion carotid endarterectomy (n = 30), performed between 2019-2020 in a tertiary center under intermediate-deep ultrasound-guided cervical plexus block and sedation, were prospectively observed and analyzed. Hemodynamic (blood pressure, heart rate) and neurological (cerebral oximetry) variables were measured in four intraoperative phases: at the beginning of the operation, prior to carotid clamping, after unclamping and at the end of the operation. We assessed acute postoperative pain in a numerical rating scale at 6, 12 and 24 h, early and 30-day complications, and length of stay. (3) Results: Baseline mean arterial pressure values were 100.4 ± 18 mmHg, pre-clamping 95.8 ± 14 mmHg, post-clamping 94.9 ± 11 mmHg, and at the end of the operation 102.4 ± 16 mmHg. Cerebral oximetry values were 61.7 ± 7/62.7 ± 8, 68.5 ± 9.6/69.1 ± 11.7 and 68.1 ± 10/68.1 ± 10 for the left and right hemispheres at baseline, pre- and post-clamping, respectively. The pain assessment showed a score less than or equal to 3. The incidence of residual nerve block, early complications, and major complications in the first 30 days was 40%, 16.7% and 3.3%, respectively. (4) Conclusions: The combination of intermediate-deep cervical plexus block and low-dose sedation is an effective and safe alternative in awake eversion carotid endarterectomy.

Multicenter Experience With Large Diameter Balloon-Expandable Stent-Grafts for the Treatment of Infrarenal Penetrating Aortic Ulcers.

PURPOSE: To describe the use of large-diameter balloon-expandable stent-grafts (BeGraft aortic stent-graft, Bentley InnoMed GmbH, Hechingen, Germany) in the treatment of infrarenal penetrating aortic ulcer (iPAU). MATERIALS AND METHODS: Retrospective analysis of patients undergoing endovascular treatment with the BeGraft aortic stent-graft in 8 European centers from January 2017 to October 2020. Demographics, perioperative data, and midterm outcomes were collected. Endpoints of the study were technical feasibility, early mortality, and morbidity. RESULTS: A total of 40 patients were included. The mean age was 73.9±7.05 years and 63.2% were male. Indications for treatment included size and morphology (65%), presence of symptoms (29.5%), and contained ruptures (5.5%). Urgent treatment was performed in 5% of cases. Technical success was 97.5%. Median operation time was 58 minutes (19-170 minutes), with 27.5% of patients having additional procedures during the main intervention (1 additional repair with a C-TAG (W.L. Gore & Associates, Inc, Flagstaff, AZ, USA) thoracic endoprosthesis, 5 covered endovascular reconstruction of aortic bifurcation procedures, 3 extensions with proximal cuffs, and 2 percutaneous angioplasties of the common iliac arteries). Percutaneous femoral access was used in 72.5%, while groin cut-down was performed in 27.5%. Repair was successful with only 1 stent in 45% of cases, while 37.5% required 2 stents and nearly 17.5% required 3/4 stent-grafts. The 30-day mortality was 0%, with a 2.5% reintervention rate (1 patient required evacuation of an intra-abdominal hematoma). Median follow-up was 13.9 months (2-39 months), during which no vascular-related reinterventions or deaths were reported. In 4 patients, a type II endoleak was observed. No cases of graft migration, thrombosis, or stent-fracture were observed. CONCLUSIONS: The treatment of iPAU with the BeGraft aortic stent-graft in a selective patient group is feasible with low rate of perioperative morbidity and mortality. Balloon-expandable stent-grafts offer the option to repair iPAUs with a shorter coverage of the aorta using low-profile sheath, that enables treatment in the presence of calcified access vessels and small diameter aortic bifurcations.

Midterm Results of Endovascular Treatment for Complete Iliac Axis Occlusions Using Covered Stents.

BACKGROUND: Endovascular treatment of complex aortoiliac disease is seeing a growing popularity despite the Trans-Atlantic Inter-Society Consensus (TASC) II recommendations for open surgery in this cases. However, the available evidence does not focus particularly on patients with complete unilateral iliac axis obstruction (CIAO) (TASC II D4 group). This study reports mid-term results of endovascular therapy with covered stents for CIAO. METHODS: This is single-center retrospective review of patients with CIAO endovascular treatment from January 2015 to December 2017 (3 years). Two types of covered stents were used, alone or combined: the Viabahn self-expandable stent (W. L. Gore, Flagstaff, AZ) and the Advanta V12 balloon-expandable stent (Atrium-Maquet, Hudson, NH). Thirty-day outcomes, long-term patency (assessed with Kaplan-Meier estimates), in-hospital stay, and limb salvage were analyzed. RESULTS: Thirty-nine patients with CIAO were treated in the period (87.2% male, mean age 64.3 ± 9 years). A majority presented with critical limb ischemia (56.4%, n = 22). Recanalization could be accomplished from an ipsilateral or contralateral femoral access in 82.1% of patients (1 case needed the use of a re-entry device), and from a left brachial access in 17.9%. Technical success was 100%. About 66.7% of cases received an aortic kissing stent technique. Common femoral artery/profundoplasty with prosthetic or bovine patch was associated with 74.3% of cases. Thirty-day mortality was 2.6% (1/39). Primary, assisted, and secondary patency rates at 24 months were all 96.8%. Mean in-hospital stay was 5 days; no limb loss was registered during follow-up. CONCLUSIONS: Endovascular treatment of complete iliac axis occlusions can offer comparable midterm patency rates to open surgery aortoiliac femoral bypass, when an adequate combination of balloon and self-expandable covered stents is used and an appropriate outflow through the common femoral artery is warranted.

Hybrid Repair of an Innominate Artery Mycotic Aneurysm with an "On-The-Table" Customized Endograft.

BACKGROUND: The objective of this report is to present a challenging case of a mycotic aneurysm of the innominate artery (IA) in a patient with a bovine aortic arch. MATERIALS AND METHODS: An 85-year-old woman presented with intermittent fever and positive blood cultures for Staphylococcus aureus. An echocardiogram and a positron emission tomography-computed tomography were performed, showing a hypermetabolic dilation of the IA compatible with a mycotic aneurysm with a type one bovine aortic arch. Conventional open arch repair and total endovascular repair with a custom-made aortic endograft were rejected given the elderly age and need for urgent repair. Treatment was achieved with a hybrid procedure, including a left carotid transposition and exclusion of the aneurysm with a modified Endurant II® iliac limb (two stents were cut off and it was resheathed in an inverted fashion) released through a prosthetic graft sutured onto the right axillary artery, followed by coil embolization of the sac. One year after the repair, the patient is well with complete exclusion of the aneurysm. CONCLUSIONS: Under the need for urgent repair, "on-the-table" modification of standard endograft components can be an effective solution for aneurysm exclusion when off-the-shelf endovascular stent grafts do not meet the anatomical requirements.

Infrarenal Aortic Endograft Infection: A Single-Center Experience.

PURPOSE:: Endograft infection is an infrequent but one of the most serious and challenging complications after endovascular aortic repair. The aim of this study was to assess the management of this complication in a tertiary center. CASE SERIES:: A retrospective analysis of a prospective database was performed including all patients who underwent elective endovascular abdominal aortic repair (EVAR) from 2003 to 2016 in a tertiary center. Seven cases of endograft infection were identified during the follow-up period from a total of 473 (1.48%) EVAR. Most frequent symptoms at presentation were fever (71.4%) and lumbar pain (57.1%). One case developed an early infection, while 6 cases were diagnosed as late infections. Mean time from endograft placement to symptom presentation was 28.3 months (2-91.5 months). Gram-positive cocci were the microorganisms most commonly isolated in blood cultures (66%). Two cases were managed with endograft removal and aortic reconstruction with a cryopreserved allograft, 2 cases with surgical drainage, and 2 cases exclusively with antibiotic therapy. In 1 case, the diagnosis was performed postoperatively based on intraoperative findings associated with positive graft cultures; and graft explantation was performed with "in situ" reconstruction using a Dacron graft. Perioperative mortality was 42.9%. One-year mortality was 57.1%. Mean follow-up was 21.5 months. CONCLUSION:: Endograft explantation is the gold standard of treatment; however, given the overall high morbi-mortality rates of this pathology, a tailored approach should always be offered depending on the patient's overall condition. Conservative management can be an acceptable option in those patients with short life expectancy and high surgical risk.

The Use Of The Gore® Hybrid Vascular Graft For Treatment Of Complex Iliofemoral Revascularization Procedures.

PURPOSE: To describe the uses and advantages of hybrid vascular grafts (HVGs) for complex iliofemoral revascularization procedures. CASE REPORT: We report 3 cases of iliofemoral occlusions repaired with the Gore HVG, used as an alternative technique to standardized common femoral artery (CFA) endarterectomy associated with iliac stenting or open repair. The indication in each of the 3 cases was different: In the first case, there was an absent CFA secondary to a mycotic pseudoaneurysm, in the second case, an iatrogenic lesion of the posterior wall of the CFA during the intervention was performed, and in the third case, the indication was because of thrombosis of a previous iliofemoral revascularization procedure. CONCLUSION: Although we only present 3 cases, the Gore HVG can be useful for complex iliofemoral revascularizations, serving as an alternative to standardized CFA endarterectomy plus iliac stenting in cases where there is a damaged or absent CFA, especially in high-surgical risk patients.

Debranching aortic surgery.

Conventional open surgery still remains as the gold standard of care for aortic arch and thoracoabdominal pathology. In centers of excellence, open repair of the arch has been performed with 5% immediate mortality and a low rate of complications; however overall mortality rates are around 15%, being up to 40% of all patients rejected for treatment due to their age or comorbidities. For thoracoabdominal aortic pathology, data reported from centers of excellence show immediate mortality rates from 5% to 19%, spinal cord ischemia from 2.7% to 13.2%, and renal failure needing dialysis from 4.6% to 5.6%. For these reasons, different alternatives that use endovascular techniques, including debranching procedures, have been developed. The reported results for hybrid debranching procedures are controversial and difficult to interpret because series are retrospective, heterogenic and including a small number of patients. Clearly, an important selection bias exists: debranching procedures are performed in elderly patients with more comorbidities and with thoracoabdominal aortic aneurysms that have more complex and extensive disease. Considering this fact, debranching procedures still remain a useful alternative: for aortic arch pathology debranching techniques can avoid or reduce the time of extracorporeal circulation (ECC) or cardiac arrest which may be beneficial in high-risk patients that otherwise would be rejected for treatment. And compared to pure endovascular techniques, they can be used in emergency cases with applicability in a wide range of anatomies. For thoracoabdominal aortic aneurysms, they are mainly useful when other lesser invasive endovascular options are not feasible due to anatomical limitations or when they are not available in cases where delaying the intervention is not an option.

Hybrid aortic repair with antegrade supra-aortic and renovisceral debranching from ascending aorta.

Aortic dissection is a life threatening condition. Hybrid repair has been described for the treatment of complex aortic pathology such as thoracoabdominal aortic aneurysms (TAAA) and type A and B dissections, although open and total endovascular repair are also possible. Open surgery is still associated with substantial perioperative morbi-mortality rates, thus less invasive techniques such as endovascular repair and hybrid procedures can achieve good results in centers with experience. We present the case of a patient with a chronic type B dissection and TAAA degeneration that was treated in a single stage hybrid procedure with antegrade supra-aortic and renovisceral debranching from the ascending aorta and TEVAR. At three-year follow up, the patient is free of intervention-related complications.