Proctorship for CAS training: a pilot study of safety and reproducibility.

AIM: The literature continues reporting a high complication rate for carotid artery stenting (CAS) during the learning-curve phase (LCP). The aim of this study was to report a simple and reproducible method designed to improve CAS results during the LCP. METHODS: Between February 2007 and December 2009, a qualified vascular surgeon ran a proctorship program for CAS. The program was divided into four practical phases: in the teaching phase (a) the first 20 CAS were performed by the proctor assisted by a trainee surgeon; in the training phase (b) for the 21st to the 50th CAS the trainee surgeon was supervised by the proctor; in the skilled phase (c), between the 51st and the 80th procedure, a trainee surgeon performed CAS while the proctor was scrubbed-in but operating only on demand; in the final phase (d), following the 81st CAS, the procedure was performed without the proctor's presence. The inclusion criterion was carotid stenosis ≥70% and patient selection was performed for the first 40 cases based on patient and lesion characteristics. The procedure for CAS was standardized. RESULTS: Four trainees performed 604 CASs in two centers. The procedural success rate of CAS was 98.8% (N.=594/604) without any differences among the four trainees (P=0.902). The overall TIA, myocardial infarction, minor, major and fatal stroke rate at 30 days was respectively 1.7% (N.=10), 0.8% (N.=5), 1.2% (N.=7), 0.64% (N.=4) and 0.3% (N.=2). The effectiveness of this program was demonstrated by a significant decrease in the proctor's intervention between phase b and phase c (P<0.001) and by a similar trend in the complication rate achieved by the four trainees, in all phases and centers (P=0.075 and 0.788, respectively). CONCLUSION: This preliminary experience of a proctorship program in the LCP, together with patient selection and standardization of the procedure and materials used, seems to be safe and reproducible. Moreover, possibly randomized, studies comparing different CAS training techniques are needed in order to validate our findings.

Hybrid open and endovascular repair of recurrent visceral aortic patch aneurysmal expansion after previous thoracoabdominal aortic aneurysm repair: case report and description of technique.

The rate of morbidity and mortality in patients undergoing open repair for thoracoabdominal aortic aneurysm (TAAA) still remains too high, ranging from 2% to 40%. In recent years "hybrid" techniques have been developed (EVAR and retrograde surgical revascularization) for the treatment of TAAA. This procedure has proved to be more effective to reduce the high risks of complication related to this kind of operation resulting in a lower morbidity and mortality rates when compared to traditional surgical techniques. A 77-year old patient who had previously been undergone surgical exclusion of a TAAA by using a straight aorto to aortic bypass graft (end to end fashion) with visceral patch, was referred to our behalf for the presence of a recurrent Crawford Type IV aortic aneurysm expansion of 10.5 cm length on diameter. Considering the serious co-morbidities of the patient and the high risk of mortality related to the traditional redo surgery, the hybrid technique was considered to repair this recurrent aneurysm by using a surgical debranching of the visceral and renal arteries from the aorta associated to the their retrograde revascularization before to perform the endovascular exclusion of the aneurysm at the same time in a single operation. Over a period of 12 months the patient was alive in good health, a follow-up by computed tomography (CT) scan confirmed the correct position of the endograft, without endoleaks, the patency of the bypasses and the reduction on diameter of the aneurysmal sac. The combined hybrid procedure (endovascular and open surgical approach) for treatment of complex TAAA is to be considered a feasible and effective surgical technique, but a larger number of cases and a longer follow-up are required either to validate this procedure or to get a more significant and statistical comparison to the traditional approach.

Combined spinal and epidural anesthesia for open abdominal aortic aneurysm surgery in vigil patients with severe chronic obstructive pulmonary disease ineligible for endovascular aneurysm repair. Analysis of results and description of the technique.

This study evaluated the feasibility of open infrarenal abdominal aortic aneurysm (AAA) surgery under peridural and spinal anesthesia (vigil patient) alone in high-risk patients with severe chronic obstructive pulmonary disease (COPD) ineligible for endovascular aneurysm repair (EVAR) or open surgery in general anesthesia. Between January 2005 and July 2007, seven patients underwent open AAA surgery with combined spinal and epidural anesthesia ([CSEA] without intubation) alone. Regional abdominal anesthesia was established by spinal anesthesia at L2-3 (levobupivacaine plus fentanyl) associated with peridural anesthesia at T7-8 (levobupivacaine). In this series (6 males and 1 female) the average age was 76.5 years (70-87); the AAA measured 7 cm in diameter on average (range 6-12.2). The survival rate was 100% (7/7 patients) at 6-12 months postoperative; no morbidities occurred during the postoperative phase. Owing to the small size of the series, no statistically significant conclusions can be drawn; even so, repair surgery was found to be effective, without the occurrence of morbidities or mortalities. In high-risk patients (severe COPD), open surgical repair of infrarenal AAA may be done with CSEA alone without intubation when, because of the patient's health, general anesthesia would pose too high a risk or when EVAR is unfeasible. Furthermore, the authors believe that surgical AAA repair under CSEA in vigil patients is a valid treatment option in those subjects with a high operative risk (severe COPD) and untreatable by either open AAA surgery under general anesthesia or EVAR.

Visceral artery aneurysms: series of 17 cases treated in a single center.

AIM: The aim of this study is to evaluate early and long term results obtained with a retrospective review in 8-year experience with surgical/endovascular treatment of visceral artery aneurysm (VAA) in a single center. METHODS: Between 2001 and 2008 in our vascular surgery unit visceral artery aneurysms were diagnosed with CT and/or angiography in 17 patients (9 male), mean age 66 years old (range: 18 to 78). All patients underwent surgical or endovascular treatment of splanchnic artery aneurysm. In 14 patients the localization was single, in 3 it was multiple. The arteries involved were: splenic artery 53%, superior mesenteric artery 17.7%, pancreaticoduodenal artery 17.7%, celiac axis 5.8% and hepatic artery 5.8%. The 29.4% of the patients presented with aneurysm rupture. Coil embolizzation was used in 11.6% of the cases while surgery was used in 88.4% of the cases. RESULTS: Total survival rate was 94.2%, the survival rate in emergency cases was 80% while it was 100% in elective cases. Follow-up revealed excellent results after an average of 46 months (range: 8-102). CONCLUSION: The worst prognosis for ruptured cases associated with the good result of the surgical/endovascular treatment in elective cases, suggests active interaction for such pathologies; in emergency cases the mortality incidence is too high. Today endovascular treatment presents lower morbidity and mortality rates and shorter hospitalization, but surgery is still a good therapeutic option for the treatment of the VAA, in subjects with low surgical risk, determining a definitive and long-lasting correction of the aneurysmal pathology and guaranteeing the correct perfusion of the organs, by grafts; moreover many aneurysms are not suitable for endovascular treatment.

Isolated aneurysm of the inferior thyroid artery repair with coil embolization.

A 68-year-old female patient with a suspected aneurysm of the inferior thyroid artery was admitted to the authors' Unit of emergency after an accident. The echography of the thyroid revealed a ''suspected'' aneurismal dilation of the inferior thyroid artery (max. diameter 30 mm.). The patient underwent an angiograph of the supra-aortic trunk, which detected a small round formation at the base of the left inferior thyroid artery (found to be unaffected by aneurismal pathologies), the aneurysm was excluded by coil embolization. The postoperative course was uneventful and the patient was discharged in one day without complications. The follow-up with colour Duplex, at 4-8 months, showed the normal vascularization of the neck arterial vessels and was confirmed the absence of aneurysmal dilations. Aneurysms of the inferior thyroid artery are extremely rare, in scientific literature only 28 cases have been reported of which 32.9% regard ruptured aneurysms in the thyroid artery and 10.7% led to mortality. They may cause dysphagia and/or respiratory difficulties. Therefore, treatment is always recommended, even in asymptomatic cases, by surgical exclusion or coil embolization.

Early experience with the minimal extracorporeal circulation system (MECC) during thoracoabdominal aortic aneurysm repair.

AIM: The purpose of this report is to describe our early experience with a minimal extracorporeal circulation system (MECC), a compact closed heparin coated system consisting of a centrifugal pump and a membrane oxygenator, during thoracoabdominal aortic aneurysm (TAAA) repair. METHODS: Between January and December 2002 the MECC system was employed in seven consecutive patients (four TAAA type II, two TAAA type I and one TAAA type III according to the Crawford classification). In all patients distal aortic, selective renal and visceral perfusion was performed with this compact closed heparin coated system consisting of a centrifugal pump and a membrane oxygenator. RESULTS: The MECC system was used in all cases with no technical malfunctions. Six out seven patients were discharged from the unit. One patient developed paraplegia after TAAA repair and died on the third post-operative day from multi-organ failure. In this case the total spinal ischaemic time was 120 min and the distal aortic perfusion pressure was <50 mmHg. No cardiac, cerebral, renal, hepatic or bleeding complications were recorded in the remaining six patients. CONCLUSION: Our early experience with MECC during TAAA repair showed that it is feasible for distal aortic spinal and visceral selective perfusion. Further large clinical trials are required to determine the efficacy of this technique.

Intra-operative assessment of technical defects after carotid endarterectomy: a comparison between angiography and colour duplex scan.

We compared the intra-operative diagnostic value of CDS vs IA-DSA in identifying major and minor technical defects after CEA. Between August 1997 and December 1998, 138 consecutive patients undergoing 141 carotid endarterectomies were intra-operatively investigated with colour duplex scan and intra-arterial digital subtraction angiography. Thirty-six (25.5%) technical defects were identified. Four (11.1%) major defects were detected by both methods and they were immediately corrected. Fifteen (41.6%) minor defects were detected by both methods, thirteen (36.1%) minor defects were detected by colour duplex but ignored by angiography. Angiography detected four (11.1%) kinkings missed with the colour duplex. The overall sensitivity of both methods for major defect was 100%. The sensitivity of colour duplex for minor defects was 87% vs 59% for angiography. On the basis of our study, colour duplex could be considered the choice method for quality control after carotid endarterectomy.