Percutaneous Saphenous Vein Arterialization.

PURPOSE: In patients with no-option critical limb-threatening ischemia, venous foot arterialization can be considered the last chance before major amputation. Up until now, a really significant limitation of endovascular arterialization compared with surgery was the possibility to obtain arterial flow into the foot only through the deep plantar network. TECHNIQUE: Two 5-mm snares are placed: one in the proximal tibial artery and the other in the great saphenous vein. After passing through these snares with a needle and a guidewire and closing the snares, the guidewire is pulled through the proximal arterial sheath and the distal venous sheath. Thus, the arterial-venous connection is created. A covered stent is, then, placed between the artery and the vein to avoid leakage. CONCLUSIONS: Based on our knowledge, this is the first described totally percutaneous arterialization of the superficial dorsal venous foot system, through reverse flow in the great saphenous vein.

Treatment of bypass failure in patients with chronic limb threatening ischemia - open surgery vs. percutaneous mechanical thrombectomy.

Background: Lower limb bypass occlusion in patients with chronic limb threating ischemia remains a challenge. We can choose between different treatment options: open surgery, local thrombolysis, thrombectomy/atherectomy devices. In this pilot study, we compare clinical outcomes and treatment costs between open surgery (OS) and percutaneous mechanical thrombectomy (pMTH). Patients and methods: This pilot study represents a retrospective analysis of hospital data of 48 occluded bypasses admitted from 2013 to 2018. Only patients presenting with severe ischemia and recrudescence of symptoms (Rutherford 4-6) were included in the current analysis. Two cohorts of patients were analysed: patients who underwent OS and patients that underwent pMTH. Primary clinical outcomes were one-year cumulative patency and limb salvage rates. Total cost was calculated as a sum of intra- and post-operative costs. To weigh clinical benefits against the economic consequences of OS versus pMTH a cost-effectiveness framework was adopted. Results: We analysed a series of 48 occluded bypasses 17 treated with open surgery and 31 with pMTH. Procedural success was 100% in both groups. When comparing one-year death rates (p-value = .22) and re-occlusion rates (p-value = .43), no statistically significant differences were observed between the two cohorts. Mean patency duration in the surgery cohort was significantly shorter (p-value < .05). Primary patency (OS 41.2% vs. pMTH 48.4%) and limb salvage rate (OS 88.2% vs. pMTH 90.3%) at one year are similar in both groups. The total cost of surgery was substantially higher (OS 10,159€ vs. pMTH 8,401€) Conclusions: This pilot study, although limited to 48 occluded bypasses, demonstrates that endovascular treatment with pMTH is less invasive, less time consuming and less expensive, and produces greater health benefits than traditional OS.

An Italian experience with mechanochemical ablation of the saphenous vein since 2012.

OBJECTIVE: Mechanochemical endovenous ablation is a nonthermal method to ablate superficial incompetent veins. The aim of this paper was to assess short-term complications and 5-year follow-up outcomes. METHODS: This is a retrospective single-center study of data collected prospectively. We treated, in an outpatient setting, 395 primary, symptomatic, unilateral, incompetent varicose saphenous veins. No patients were treated bilaterally in the same session. The majority were great saphenous veins (92.3%), and the others were small saphenous veins. Procedures were performed with a mechanochemical endovenous occlusion catheter (ClariVein endovenous occlusion catheter; Merit Medical, South Jordan, Utah) and polidocanol 2% in liquid form. RESULTS: Follow-up was available for 329 patients treated between September 2012 and September 2017 with a mean follow-up time of 20 ± 18 months (range, 6-60 months). Technical success was achieved in 99.5%; in two patients, we were unable to complete the procedures because of vein spasm leading to catheter damage and inability to infuse the sclerosant. Follow-up was performed with clinical evaluation and duplex ultrasound scan at 1 week, 1 month, 6 months, and 1 year and then once every year. The overall survival rate free from recanalization was 92.4%. Anatomic success is 94% at 1 year, 91% at 2 years, 88% at 3 years, 88% at 4 years, and 84% at 5 years. The follow-up at 5 years includes 23 patients, 5 of whom presented with recanalization; moreover, in this series, in 36% of cases, the veins completely disappeared on duplex ultrasound scan. CONCLUSIONS: The ClariVein catheter is associated with a good occlusion rate, comparable with other techniques including thermal techniques, without major complications.

Neurocognitive changes after eversion carotid endarterectomy under local anesthesia.

BACKGROUND: The effects of carotid endarterectomy (CEA) on cognitive function have yet to be fully elucidated. The aim of our study was to administer a battery of cognitive tests to identify any cognitive changes occurring in a consecutive series of patients who underwent CEA using the eversion technique under local anesthesia. METHODS: This prospective study was designed to analyze a consecutive series of patients undergoing eversion CEA under local anesthesia for significant carotid stenosis at our vascular surgery unit over a period of 6 months. Patients underwent tests to rule-out those who already had cognitive impairments or states of depression/anxiety capable of interfering with cognitive testing outcomes. Patients then completed a battery of 10 neurocognitive tests preoperatively and again 30 days and 4 months after surgery to assess the functions of both cerebral hemispheres as thoroughly as possible. RESULTS: Of the 48 patients initially considered for our study, 39 completed the follow-up. They were 71.4 ± 8.2 (mean ± SD) years of age; 30 were men and 9 were women. Six were symptomatic for carotid stenosis and 33 were asymptomatic. All patients were examined by a neurologist and underwent pre- and postoperative nuclear MRI or CT scan of the brain to identify any cerebral ischemia potentially correlated with the surgical procedure. In all cases, the cognitive test findings tended to improve postoperatively; this improvement was statistically significant in 7 tests. Post-hoc analysis confirmed an improvement between the pre- and postoperative test results. Among the different variables considered, only age <75 years seems to have influenced cognitive improvement. CONCLUSIONS: The effects on cognitive function of carotid stenosis, particularly CEA, is still a much debated issue. The data reported in the literature vary considerably, preventing any final conclusions from being drawn. The mechanisms capable of inducing changes in cognitive status after CEA have yet to be precisely clarified. In our study, a suitable battery of tests were used to analyze the trend of cognitive function correlating with eversion CEA under local anesthesia. Our results demonstrate substantially improved cognitive function after CEA, which was statistically significant in 7 of 10 tests. We surmise that the CEA procedure, per se, can help to protect patients against cognitive deterioration, especially in those <75 years of age.

Treatment of type II endoleak with a transcatheter transcaval approach: results at 1-year follow-up.

PURPOSE: This study assessed the feasibility and mid-term outcomes in the treatment of type II endoleak using transcatheter transcaval embolization (TTE). METHODS: During an 8-month period, 12 patients underwent TTE. After direct transcaval puncture of the aneurysm sac, embolization was performed by injecting thrombin and placing coils. Systemic and intrasac pressures were recorded throughout the entire procedure. Computed tomography (CT) scans were performed at 24 hours, 30 days, 6 months, and 1 year after TTE to evaluate endoleaks and changes in sac diameter. Technical success was defined as the feasibility of the procedure; clinical success was defined as no evidence of leaks during the follow-up evaluation. RESULTS: TTE was feasible in 11 of 12 patients (technical success 92%). The mean systemic pressure was 117 mm Hg. The mean intrasac pressure before embolization was 75 mm Hg (range, 39 to 125 mm Hg), 16.5 mm Hg (range, 7 to 40 mm Hg) in 10 patients after embolization, and it increased in one patient. CT scans at 24 hours showed stable contrast medium inside the sac in 10 patients. Only minor complications were observed during follow-up. At the 1-year follow-up, no recurrence of leaks was noted, and sac diameter was reduced in 10 of 11 patients. As a result, TTE clinical success was obtained in 10 (83%) of 12 patients. CONCLUSION: TTE appears to be a feasible technique for the complete exclusion of type II endoleaks. Technical and clinical successes are comparable with other treatment strategies, and TTE should be considered an alternative to direct translumbar puncture of the aneurysm sac.