The PROTAGORAS 2.0 Study to Identify Sizing and Planning Predictors for Optimal Outcomes in Abdominal Chimney Endovascular Procedures.

OBJECTIVE: The aim was to identify predictors of adequate pre-operative sizing and planning for chimney endovascular aortic repair (ChEVAR) in order to reduce the incidence of persistent type Ia endoleaks (IaELs) without influencing chimney graft (CG) patency. METHODS: Consecutive patients who underwent ChEVAR between January 2009 and December 2017 at a single centre were evaluated retrospectively. Included were patients treated with one device combination (Medtronic Endurant mated with Getinge Advanta V12/iCast) and placement of single or double CG. The freedom from IaEL related re-interventions and primary CG patency was estimated by measuring aortic stent graft oversizing (OS), total neck length (TNL), and a composite parameter (L-OS: TNL [mm] + OS [%]). RESULTS: Seventy-three patients who underwent placement of 101 CGs (45 single, 28 double) met the inclusion criteria. The median radiological follow up was 25.5 (interquartile range [IQR] 12-48) months. Freedom from IaEL related re-intervention was achieved in 94.6% with a median OS of 38.5% (IQR 30%-44%, p = .004), TNL 19 mm (16-25 mm, p = .62), and L-OS 59 (51-65, p = .018). Primary CG patency was achieved in 95% of the cases with a median OS of 36% (29%-42%, p = .008), TNL 19 mm (15.5-26 mm, p = .91), and L-OS 57 (50-64, p = .005). By using the receiver operating characteristic curve, an optimal cut off to prevent IaEL related re-interventions was identified by an OS of 30% (p < .001; L-OS 55, p = .006) and to avoid CG stenosis/occlusions by OS 42% (p < .001; L-OS 65, p < .001). In multivariable analysis, aortic endograft OS was the only independent parameter preventive for IaEL related re-intervention (odds ratio, 0.78; 95% confidence interval, 0.61-0.99). CONCLUSION: With the Endurant-Advanta V12/iCast combination, an aortic stent graft OS of at least 30% (range 30%-42%) should be used to avoid type Ia endoleaks and likewise to ensure CG patency.

Duplex ultrasound versus CT angiography for the treatment planning of lower-limb arterial disease.

PURPOSE: This study aimed to assess the diagnostic accuracy of duplex sonography (DUS) compared with that of computed tomography angiography (CTA) in detecting occlusion and stenosis in peripheral arterial disease (PAD) in candidate patients for endovascular revascularization with intraprocedural digital subtraction angiography (DSA). METHODS: The study involved 94 patients suffering from PAD who were candidates for endovascular procedures requiring DSA. They were all submitted preoperatively to DUS and CTA. Based on image analysis, five segments of the arterial tree were assessed: iliac, common femoral, superficial femoral, popliteal, and infrageniculate. According to the stenosis or occlusion degree, the arteries were rated as nonstenotic, stenotic, and occluded. RESULTS: The agreement between DUS and CTA findings using DSA as a reference modality was expressed as a Cohen's kappa (κ) statistic agreement. Our results show that DUS has been less accurate than CTA in evaluating iliac arterial diseases (Cohen's κ agreement of 0.91 and 1.0, respectively) when measured against DSA. We found good diagnostic concordance between DUS and DSA in detecting hemodynamic stenosis and occlusion of the femoro-popliteal axis (Cohen's κ agreement between 0.96 and 0.93). Below the knee, CTA showed even less concordance with DSA (Cohen's κ 0.75). CONCLUSIONS: Because of its accuracy, high-quality DUS performed by well-trained operators may therefore represent a good alternative to CTA in patients undergoing endovascular revascularization to minimize the use of contrast-enhanced radiological imaging. Nevertheless, preoperative CTA imaging is required in cases of nondiagnostic DUS or when a more complete overview of the vascular tree is needed for complex invasive interventions.

Is Low Inferior Mesenteric Artery Ligation Worthwhile to Prevent Urinary and Sexual Dysfunction After Total Mesorectal Excision for Rectal Cancer?

BACKGROUND/AIM: We studied the role of high or low inferior mesenteric artery (IMA) tie on defecatory, sexual and urinary dysfunctions in patients who underwent laparoscopic TME for early rectal cancer. PATIENTS AND METHODS: Forty-six consecutive patients undergoing curative laparoscopic resection for pT2N0M0, rectal adenocarcinoma from February 2013 to March 2019 were enrolled into this prospective randomized open label parallel trial to have a laparoscopic TME with a high (Group 1) or low IMA ligation (Group 2). Demographic data and information on symptoms and comorbidity, intra- and post-operative outcomes and defecatory, sexual and urinary functions before and after surgery according to the validated International quality of life questionnaires. RESULTS: A significant difference in postoperative total score of FIQL scale, Jorge-Wexner incontinence score and Agachan-Wexner constipation score were observed between the high and low tie groups at 1, 6, and 12 months after surgery. ICIQ-UI short form, FSFI, and IIEF demonstrated at 1, 6 and 12 months, the scores were significantly higher for patients of Group 1 as compared to those of Group 2. CONCLUSION: A low IMA ligation permits a better fecal continence, less abdominal pain, and less genito-urinary and sexual dysfunctions in patients submitted to TME for rectal cancer.

Post-implantation syndrome: the impact of different devices for endovascular abdominal aortic aneurysm repair and related etiopathogenetic implications.

BACKGROUND: Postimplantation syndrome (PIS) is a systemic inflammatory response occurring in early phase after abdominal aortic aneurysm (AAA) endovascular repair (EVAR). PIS can also occur after endovascular aneurysm sealing (EVAS) with Nellix system which prevent new onset of mural thrombus inside. Aim was to compare the incidence of PIS after EVAS and EVAR to evaluate the possible role of the new-onset thrombus inside the aneurysmal sac. Secondary aims were to assess the effect of AFX (Endologix) endoskeleton compared with other commercially available exoskeleton PTFE stent grafts on inflammatory response and its relationship with the clinical outcomes. METHODS: From 2013 to 2017, data on 60 elective EVAS with Nellix system (Endologix, Irvine, CA, USA) and 110 EVAR with ePTFE devices (56 AFX devices and 54 other stent grafts) for AAA patients were retrospectively collected. PIS was defined as composite of body temperature ≥38 °C coinciding with leukocyte count >12,000/mL and hs-CPR >10 mg/L. New-onset thrombus volume after EVAR was calculated by: endograft volume - preoperative luminal volume=volume of new-onset thrombus, whereas post-EVAS thrombus volume was calculated from difference between AAA volume and volume of Nellix endobags, including balloon expandable stents. Nonparametric χ2 distribution with corresponding P values were used to assess differences among categorical variables with regard to endograft type. Threshold of statistical significance was P<0.05. Subgroup analysis of outcomes by stent-graft design was performed using independent-samples t-test. RESULTS: EVAS with Nellix system was associated with lower incidence of PIS compared to EVAR using both AFX device and other endografts (8.3%, 30%, 35%, respectively, P=0.001). No significant new-onset of mural thrombus occurred following EVAS while an avarage new-onset thrombus of 21% and 14% was found in EVAR group A and group B, respectively. No statistically significant difference of PIS incidence was observed after endoskeleton AFX device deployment compared with other EVAR exoskeleton endografts. During follow-up, major complications were proportionally but not significantly (P=0.43) less frequent after EVAS (10.3%) than after EVAR and after EVAR using AFX device (8.9%) than after EVAR with other PTFE stent grafts (16.4%). CONCLUSIONS: The etiology and pathophysiology of PIS is not yet well understood. It is speculated that the type of the stent graft or the mural thrombus within the AAA may play a role in determing this inflammatory response. In this study, PIS was significantly less frequent after EVAS than EVAR. The lower inflammatory reaction observed after EVAS might be related to the endobags of Nellix system which completely seal the aneurysm sac reducing the new onset of mural thrombus. This could confirm the role of new-onset mural thrombus in the genesis of PIS. The systemic inflammatory response does not significantly differ after endoskeleton AFX device deployment compared with other EVAR exoskeleton stent grafts. PIS does not seem to have any significant prognostic implications in terms of major adverse events.

Open Conversion for Recurrent Endograft Occlusion after Endovascular Treatment of Blunt Traumatic Aortic Injury: A Peculiar Case Report.

BACKGROUND: We report a rare case of delayed, symptomatic thoracic endograft thrombosis after the initial thoracic endovascular aortic repair (TEVAR) for blunt thoracic aortic injury which was successfully retreated with a redo TEVAR, followed by open conversion due to recurrent partial occlusion of the distal edge of the endografts. METHODS: Two years ago, a 22-year-old man had undergone an emergency TEVAR for blunt thoracic aortic injury. A Zenith Cook 22 × 100 mm (Cook Incorporated, Bloomington, IN) endograft was used. Six months later, he underwent an emergency endovascular relining of the endograft using the same type of device. The multiorgan perfusion was completely restored except for the spinal cord injury. After 8 months, a recurrent partial occlusion of the distal edge of the second graft was documented. The thoracic aorta was replaced with a 22-mm silver-coated graft (Maquet Spain, SLU). RESULTS: Histology examination showed a neointimal formation and thickening and fibrosis of the inner 1/3 of the media with loss of smooth muscle cells and increase of the elastic fibers. CONCLUSIONS: The need for secondary interventions or open conversion because of potential complications after TEVAR for traumatic aortic injury is an additional consideration when weighing the risks and benefits of endovascular repair and subsequent surveillance strategies.

Incidence of Post-Implantation Syndrome with Different Endovascular Aortic Aneurysm Repair Modalities and Devices and Related Etiopathogenetic Implications.

BACKGROUND: Postimplantation syndrome (PIS) is a systemic inflammatory response occurring in an early phase after abdominal aortic aneurysm (AAA) endovascular aneurysm repair (EVAR). The pathophysiology underlying PIS is still not well understood. It is speculated that the type of the stent graft or the mural thrombus within the AAA may play a role in determining this inflammatory response. At present, there is no consensus about the influence of PIS on clinical outcomes during follow-up. The endovascular aneurysm sealing (EVAS) with the Nellix sac-anchoring endoprosthesis (Nellix Endovascular, Palo Alto, CA) is a novel modality for AAA repair, which obliterates the sac, thus preventing the new onset of thrombus in the aneurysm sac. Our aim was to compare the incidence of postimplantation syndrome following EVAS and after EVAR. Secondary aims were to assess the effect of endoskeleton AFX (Endologix) device compared with other commercially available exoskeleton PTFE stent grafts on the inflammatory response. Finally, we analyzed the potential association of PIS with clinical outcomes. METHODS: From January 2013 to June 2018, 60 AAA patients underwent EVAS (mean age 72 ± 9 years), and 110 patients were submitted to EVAR: 56 AFX devices and 54 other PTFE stent grafts (mean age 74 ± 10 years) at a single center and were retrospectively reviewed. RESULTS: EVAS with the Nellix system was associated with a lower incidence of PIS compared to EVAR using both AFX device and other endografts (8.3, 30, 35%, respectively, P-value = 0.001). No statistically significant difference in PIS incidence was observed after endoskeleton AFX device deployment compared with other EVAR exoskeleton endografts. During follow up, the major complications were proportionally but not significantly (P = 0.43) less frequent after EVAS (10.3%) than after EVAR and after EVAR using AFX device (8.9%) than after EVAR with other PTFE stent grafts (16.4%). During follow up (mean 24 months), adverse outcome rates did not significantly differ in patients with and without PIS (8.0 vs. 13.4% P = 0.43). CONCLUSIONS: Our data confirm the lower risk of PIS following EVAS compared to EVAR. Most importantly, this study highlights the role of new-onset mural thrombus in the genesis of PIS. The lower inflammatory reaction observed after EVAS than after EVAR might be related to the endobags of the Nellix system, which completely seal the aneurysm sac, reducing the new onset of mural thrombus. The systemic inflammatory response does not significantly differ after endoskeleton AFX device deployment compared with other EVAR exoskeleton stent grafts. PIS does not seem to have any significant prognostic implications in terms of early major adverse events.

Nellix Endovascular Aortic Sealing Endoprosthesis Late Explantation for Concomitant Type I Endoleak and Stent Frames Proximal Caudal Migration.

Endovascular aneurysm sealing (EVAS) using the Nellix™ System was introduced in clinical practice with the aim of reducing the incidence of complications such as migration, endoleaks, and reinterventions after conventional endovascular aneurysm repair (EVAR). Although, initial efficacy data on this device have been encouraging, EVAS has also demonstrated to undergo adverse events. Herein, we report a case of Nellix graft explant due to endobags shrinkage after air bubble reabsorption leading to proximal type I A endoleak and stent migration. The focus of this article is on the importance of a more assiduous surveillance of this new device, in particular in those cases with air into the endobags immediately after the procedure; this surveillance should be aimed to timely identify complications which can otherwise lead to consequences that require open conversion.

Single-Center Experience in the Treatment of Visceral Artery Aneurysms.

BACKGROUND: Visceral artery aneurysms (VAAs), although rare, represent a life-threatening disease with high mortality rates. With the more frequent use of diagnostic tests, there has been an incidental detection of these lesions which are mostly asymptomatic. It follows that surgeons are increasingly called to decide on the most appropriate management of VAAs between an open surgical or endovascular approach and among the different endovascular options currently available. The aim of this retrospective study was to evaluate the results of open surgery and interventional endovascular strategies of visceral artery aneurysms with respect to technical success, therapy-associated complications, and postinterventional follow-up in the elective and emergency situation. METHODS: From January 1992 to January 2017, 125 open surgical or endovascular interventions for VAA were performed at our institution. Once the VAA was diagnosed and the indication for treatment was assessed, the preoperative diagnostic work-up consisted of contrast computed tomography (CT) or magnetic resonance imaging (MRI) and, in some patients, digital subtraction angiography. Follow-up included clinical and duplex ultrasound scan (DUS) and contrast-enhanced ultrasound to assess the treated vessel patency and organ perfusion after 1, 6, and 12 months, and yearly thereafter. CT or MRI controls were also performed at 1 year of follow-up and only when DUS was not diagnostic or showed a complication thereafter. After the first 5 years of follow-up, the status of the patient was obtained by a structured telephone survey. RESULTS: The treatment option was endovascular in 56 of 125 cases (44.8%). Technical success was 98.3%. In one case, the procedure was interrupted for the extensive dissection of the afferent vessel. Twenty-six patients were treated by coil embolization while 29 with covered stenting. The endovascular approach was in emergency in two cases (3.6%). In the endovascular group, mortality was nil. Complications occurred in 5 cases (8.9%): 1 subacute intestinal ischemia caused by superior mesenteric artery dissection, 2 aneurysm reperfusion, 1 stent thrombosis, and 1 massive splenic hematoma. In 69 (55.2%) cases, surgical treatment was preferred, with 24 VAA resections and 45 arterial reconstructions. In 20 cases (29%), open surgery was performed in emergency conditions. In the surgical group, 8 emergency patients (40%) died intraoperatively. The mortality after elective surgical interventions was nil. Complications after surgery were 4 graft late thrombosis (5.8%): asymptomatic in three cases and requiring splenectomy in one. CONCLUSIONS: There is no overall consensus regarding the indications for treatment of VAA. Currently in emergent setting, the endovascular approach should be considered as the first choice because of its reduced invasiveness, faster way to access and bleeding control; this accounts for the lower morality of the interventional therapy than open surgery. Endovascular approach is effective for elective repair of VAAs, but procedure-related complications may occur in a not negligible number of patients. Given comparable mortality rates and low procedure-related complication rate, surgical approach still has space in the elective management of VAAs, especially for aneurysms unsuitable or challenging for the endovascular option in patients with low surgical risk. The size, location, and morphology of VAAs, systemic or local comorbidities, and specific anatomical situations such as previous abdominal surgery should dictate treatment choice.

Internal Carotid Stenosis Associated with Compression by Hyoid Bone.

Atherosclerotic plaques concomitantly with the hyoid bone protrusion into the internal carotid artery (ICA) are rarely reported in the literature. These plaques can be considered as arising from the turbulent flow and the shear stress caused by the close contact between the hyoid bone and the arterial wall carotid artery. The carotid stenosis was greater than 70%. We report a patient with a transient ischemic attack and a right significant carotid artery stenosis presumably due to a compression of an elongated ICA by the hyoid bone. The patient was submitted to open surgery to remove the plaque and correct the anomalous course of ICA combined with the lysis of the arterial adhesions with the right greater horn of the hyoid bone. The hyoid bone is a remote cause of injury and subsequent atherosclerotic lesions of carotid vessels. Elongation of the carotid artery can alter its course and can favor the mechanical interference with the hyoid bone and the subsequent arterial wall damage. When an external compression of the carotid artery is viewed, the endovascular treatment of the carotid artery stenosis is not advisable and open surgery is mandatory.

One-Year Outcomes after Ruptured Abdominal Aortic Aneurysms Repair: Is Endovascular Aortic Repair the Best Choice? A Single-Center Experience.

BACKGROUND: Treatment of ruptured abdominal aortic aneurysms (rAAAs) is still burdened by high morbidity and mortality. Although endovascular aortic repair (EVAR) offers encouraging results in elective setting, its role as first-line strategy to treat rAAA is still debated. Our aim was to compare early and late outcomes in patients undergoing open surgical repair (OSR) versus EVAR for rAAAs. METHODS: A retrospective review of data extracted from medical records identified 105 consecutive patients with rAAA who were submitted to open or endovascular repairs from 2008 to 2016. The primary end point was to assess the rAAA-related mortality in the immediate postoperative period, within 1 month and 1 year after OSR, and EVAR; secondary endpoints included the following: length of stay, AAA-related postoperative complications such as acute limb ischemia, myocardial infarction, renal and respiratory failure, and rAAA-related re-interventions. Statistical analysis was performed using the Fisher exact test, χ2 test, and logistic regression calculations. Early and midterm survival rates were assessed with Cox model. RESULTS: Of the 105 patients with rAAA, 70.48% underwent OSR including 41.89% which was hemodynamically (Hd) unstable and the remaining 29.52% was submitted to rEVAR. (all Hd stable). Compared with EVAR group, the OSR group had a higher rAAA-related mortality rate for both Hd stable and Hd unstable patients: 18.92% vs. 6.45% at 24 hr; (P = 0.185) 39.19% vs. 19.35% at 30 days (P = 0.082); 44.59% vs. 38.71% at 1 year (P = 0.734) If only Hd stable patients were considered, mortality following OSR and EVAR was as follows: 6.98% vs. 6.45% at 24 hr (P = 0.703); 27.91% vs. 19.35% at 30 days (P = 0.567); 32.56% vs. 38.71% at 1 year (P = 0.764). Mean length of stay for patients was 15 days after OSR and 10 days after rEVAR (P = 0.002). At 1-year follow-up, the overall rAAA-related complications incidence was higher in the rEVAR group than that in the OSR group (47.85% vs. 18.33%; P = 0.008); re-interventions were 18.33% in OSR group vs. 21.82% in EVAR group (P = 0.917). Cox model showed that instability and coronary artery disease were predictors of overall mortality of rAAAs. CONCLUSIONS: EVAR does not independently reduce 1-year mortality in comparison with OSR in Hd stable patients. Urgent EVAR for rAAAs in unstable patients can be limited by logistical problems. It follows that patients selected for OSR have a more complex aortic anatomy and worse Hd status than those submitted to rEVAR. rEVAR burdened by a higher incidence of procedure-related complications than OSR. Reconfiguration of acute aortic services and establishment of standardized institutional protocols might be advisable for improvements in the management of ruptured AAA. A careful evaluation of whether the benefits of an endovascular strategy translate into long term benefit is needed before definitive conclusions can be drawn about the advantages of EVAR as first-line strategy for ruptured aneurysms.

An Alternative Approach for Treating a Type Ia Endoleak after Conventional EVAR Using the Nellix Endovascular Aneurysm Sealing.

BACKGROUND: To report the use of a Nellix endovascular aneurysm sealing (EVAS) device, to successfully treat a type Ia endoleak (EL) after an endovascular aortic repair (EVAR). CASE REPORT: A 70-year-old man was diagnosed with a 90-mm aortic aneurysm, suspicious for being inflammatory. It was initially treated successfully, with a Medtronic Endurant (Medtronic, Minneapolis, MN, USA). Five years after the index endovascular repair, an asymptomatic type Ia EL was detected on duplex ultrasound and computed tomographic angiogram. Other endovascular solutions in the form of proximal cuff, chimney was considered difficult to execute due to challenges in planning, manipulation, and renal cannulation caused by the short proximal sealing zone above the existing stent graft and the constraints of the previous endograft. Thus, a relining of the previous endoprothesis was performed using the Nellix system (Endologix, Inc., Irvine, CA, USA). One-year follow-up imaging demonstrated successful resolution of the EL and persistent sealing of the Nellix device. CONCLUSIONS: Nellix EVAS system can be an alternative and safe option for relining a stent graft with a type Ia EL. Nellix platform can be added to the clinician's armamentarium for treating type Ia EL after conventional EVAR of infrarenal abdominal aortic aneurysm (AAA).

Localization of lipopolysaccharide from Escherichia Coli into human atherosclerotic plaque.

Experimental studies showed that gut-derived lipopolysaccharide (LPS) is pro-atherogenic, however, its relationship with human atherosclerosis is still to be defined. We investigate if gut-derived LPS from Escherichia Coli localizes in human carotid plaque and its potential role as pro-inflammatory molecule in the atherosclerotic lesion. LPS from Escherichia Coli and Toll-like receptor 4 (TLR4) were studied in specimens from carotid and thyroid arteries of 10 patients undergoing endarterectomy and 15 controls matched for demographic and clinical characteristics. Blood LPS were significantly higher in patients compared to controls. Immunochemistry analysis revealed positivity for antibodies against LPS and TLR4 coincidentally with positivity for CD68 only in the atherosclerotic plaque of carotid arteries but not in thyroid arteries; the positivity for LPS and TLR4 was greater in the area with activated macrophages. LPS concentration similar to that detected in atherosclerotic plaque resulted in a dose-dependent TLR4-mediated Nox2 up-regulation by human monocytes. These data provide the first evidence that LPS from Escherichia Coli localizes in human plaque and may contribute to atherosclerotic damage via TLR4-mediated oxidative stress.

Hypertension, Acute Stent Thrombosis, and Paraplegia 6 Months after Thoracic Endovascular Aortic Repair for Blunt Thoracic Aortic Injury in a 22-Year-Old Patient.

Thoracic endovascular aortic repair (TEVAR) is a less invasive option for managing traumatic injuries of the descending aorta in polytraumatized patients. Concerns arise when treating young patients with TEVAR. A 22-year-old male was admitted to the emergency department following a high-impact road traffic collision. Whole-body computed tomography (CT) scan documented multiple injuries, including rupture of descending thoracic aorta just below the isthmus. There was no evidence of paraplegia or stroke. We decided to treat him in an endovascular fashion with a Zenith Cook (Cook Incorporated, Bloomington, IN) endograft. Final angiography confirmed the proper positioning of the device, no infoldings, and the optimal filling of the thoracic aorta downstream of the endoprosthesis. In the postoperative period, the patient showed high blood pressure which was treated with 4 different antihypertensive drugs. He was discharged on cardioaspirine. CT scan control was scheduled after 30 days and 6 months, but he referred to our emergency department after less than 6 months with paraplegia, abdominal pain, and acute renal failure. He had independently discontinued antiplatelet therapy 3 months before. Emergency CT control documented the presence of intimal flap and thrombus at the distal edge of the device. The magnetic resonance imaging revealed ischemic damage of the spinal cord. We decided to reline the endograft using another Zenith Cook device with very good results. Renal failure and bowel pain gradually improved, but paraplegia is still present. TEVAR is the most suitable treatment for blunt thoracic aortic injury in the modern era. Concerns arise from what can happen to a young aorta receiving a stiff endovascular graft that should be carried all lifelong. These devices have been associated with acute hypertension and cardiac remodeling. Less stiffer stent grafts should be studied for young patients. High attention must be posed in the follow-up for the immediate resolution of eventual problems.

A Peculiar Case of Type 1 Endoleak after Nellix Endovascular Aneurysm Sac Sealing: Clinical Presentation and Management.

We report a case of type 1 endoleak with an outflow via a lumbar artery (LA) following Nellix endovascular aneurysm sealing (EVAS) to discuss the specific peculiarities and management of this complication. A 64-year-old man (acetylsalicylic acid 3) underwent Nellix EVAS for an asymptomatic infrarenal aortic aneurysm. The 6-month duplex scanning ultrasound and magnetic resonance imaging showed a type IA endoleak with an outflow via an LA combined with a stable aneurysmal sac size. The subsequent 9-month imaging controls showed no changes of the endoleak cavity, but there was a slight enlargement in proximal neck size associated with the distal migration of both Nellix grafts. Thus, catheter-directed embolization with detachable coils first of the LA origin and then of the endoleak cavity was carried out. Postoperative course was uneventful. The patient is endoleak free with stable sac size on 6-month computed tomography imaging investigations following the secondary intervention.

Therapeutical Options in the Management of Carotid Dissection.

BACKGROUND: The best management of carotid artery dissection (CAD) is still controversial ranging from antiplatelet medication to open surgery or endovascular treatment. In this retrospective study, we assessed the safety and efficacy of endovascular stent angioplasty for the treatment of CAD. METHODS: From February 2006 to February 2016, 44 patients (28 women and 16 men, age range 25-65 years, mean 42) with CAD were included in this study. The internal carotid artery dissection was spontaneous in 32 patients and posttraumatic in the remaining 12 (in 1 case, it was bilateral). Twenty-eight patients were treated by intravenous heparin infusion followed by standard oral anticoagulation. Carotid artery stenting was carried out in 14 cases with recurrent ischemic events despite optimal anticoagulation management. Two patients with an open trauma of the neck were submitted to a common carotid to internal carotid bypass (CC-CI bypass). The follow-up ranged from 6 to 60 months and was performed clinically first and with Doppler ultrasound and computed tomography or magnetic resonance at 6, 12, and 24 months. RESULTS: Follow-up ranged from 6 to 60 months. Mortality was nil. All patients submitted to the endovascular or surgical management had an immediate relief of their neurologic symptoms with no procedure-related complications. No thrombosis or restenosis of the CC-CI bypass or of carotid artery stents occurred during intraoperative and postoperative period and follow-up. CONCLUSION: An alternative therapeutic option is mandatory in a subset of patients regarded as being at high risk for stroke because anticoagulant therapy was either contraindicated or failed clinically with recurrent transient ischemic attacks/transient symptoms associated with brain infarction. In these selected cases, endovascular stent placement seems to be a safe and effective option to restore vessel lumen integrity and prevent stroke.

Juxtarenal Inflammatory Aneurysm Treated with Bilateral Iliac-Renal Bypass Using the Gore Hybrid Device and Total Sealing of the Aneurysmal Sac with a Nellix Device.

The aim of this study is to present the treatment of a juxtarenal inflammatory aneurysm using a Nellix device (Endologix, Inc., Irvine, CA) to seal the entire aneurysmatic aorta combined with bilateral iliac-renal bypass using the Gore hybrid vascular graft (W. L. Gore & Associates, Inc., Flagstaff, AZ). A 63-year-old man was diagnosed with a 6-cm juxtarenal inflammatory aneurysm. It was initially decided to treat him with an aorto-aortic bypass and to revascularize the 2 renal arteries with "graft to renal artery bypass" using Gore hybrid vascular grafts. Due to the high intraoperative bleeding preparing the proximal neck and the tight adhesion of the aorta to the adjacent structures, we decided to change our plans and to treat the patient using the Nellix system combined with bilateral iliac-renal bypass using the Gore hybrid vascular grafts. Contrast computed tomography control at 1 month showed complete sealing of the aneurysm sac and patent iliac renal bypasses. The reported case demonstrated that the Nellix Endovascular Aneurysm Sealing system combined with Gore hybrid vascular grafts for bilateral iliac-renal bypass showed that it can be an effective modality for the treatment of juxtarenal, inflammatory aortic aneurysm and revascularization of the renal arteries from the distal iliac arteries.

Initial single-site experience with the Ovation abdominal stent-graft system in patients with challenging aortoiliac anatomy.

BACKGROUND: Aim of the study was to evaluate the initial results of endovascular aneurysm repair with the Ovation abdominal stent-graft system in patients with challenging aortoiliac anatomy. METHODS: The Ovation stent-graft is an ultra-low profile, modular endovascular graft characterized by a 14F OD delivery system, active suprarenal fixation, and polymer-filled proximal rings that allow sealing in short (≥7 mm) proximal necks. Between November 2010 and January 2012, 14 patients with abdominal aortic aneurysms (AAA) (male: 100%, mean age: 76 years, mean AAA diameter: 54 mm) and challenging aortoiliac anatomy were treated with the Ovation endograft at a single centre. Mean patient follow-up was 5 months. RESULTS: All cases were performed under local or epidural anesthesia. No operative deaths or major complications were noted. A type I endoleak was detected on final angiogram in one case, which was successfully treated with additional ballooning and Palmaz stenting of the hooking landing zone. One patient died at 2 months due to myocardial infarction unrelated to the device or procedure. AAA-related mortality was 0%. No AAA rupture, AAA enlargement, type I or III endoleak, stent migration, access site complication, or conversion to open surgery was reported during follow-up. A type II endoleak was successfully treated with a right lumbar artery embolization at 4 months. Occlusion of an iliac axis was successfully managed with local fibrinolysis and implantation of a covered stent in the external iliac artery. CONCLUSIONS: Initial outcomes of this single-center experience suggest that the Ovation abdominal stent-graft system is a promising treatment in AAA patients with challenging aortoiliac anatomy.

Re-TEVAR for complications after blunt aortic traumatic injury stenting.

We report an endovascular approach that was used to treat two patients with previous thoracic aortic repair or endovascular repair (TEVAR) for blunt thoracic aortic injury. The first patient was a 38-year-old man who presented with distal intragraft thrombosis 24 months after TEVAR. The second patient, a 32-year-old man, developed a symptomatic distal device collapse at 39th month follow-up, associated with buttock claudication. Both patients were offered an endograft relining, complicated in the first case by distal embolization.

Outcomes in the emergency endovascular repair of blunt thoracic aortic injuries.

Thoracic aorta blunt injury (BAI) is a highly lethal lesion. A large number of victims die before obtaining emergency care. Thoracic endovascular aneurysm repair (TEVAR) is a less invasive method compared with open surgery and may change protocols for BAI treatment. This retrospective study was developed to evaluate the potential issues about thoracic endografting in the management of these patients. Twenty-seven patients with a BAI underwent aortic stent grafting. Intervention was preceded by the treatment of more urgent associated lesions in nine cases. In-hospital mortality was 7.4%. No paraplegia or ischemic complications developed because of the coverage of the left subclavian artery. In one case (3.2%), a type I endoleak was detected, proximal endograft infolding in two cases (7.4%) and endograft distal migration in further two cases were detected during follow-up (6-110 months). Thoracic endovascular aneurysm repair of BAI showed encouraging results in terms of perioperative mortality and morbidity. Concerns still remain about the potential mid- and long-term complications in younger patients.

Carotid artery free-floating thrombus caused by paradoxical embolization from greater saphenous vein ascending thrombophlebitis.

Stroke of unknown origin in young patients is seen to be closely correlated with patent foramen ovale (PFO) than stroke in patients with established stroke mechanisms. We report a case of a young woman without cardiovascular risk factors who was admitted to our emergency department with listlessness and altered mental status. The clinical examination revealed right lower limb swelling. Magnetic resonance imaging and contrast-enhanced computed tomographic scans revealed a free floating thrombus of the left internal carotid artery (ICA) with a large bilateral frontal ischemic lesion. The diagnosis of a medium-sized PFO with moderate right-to-left contrast shunting was made after transesophageal echocardiography. No other cardiac sources for embolization were detected, while an ascending thrombophlebitis of the right greater saphenous vein was detected by venous Doppler ultrasonography. These findings support the diagnosis of ICA free-floating thrombus caused by paradoxical embolization (via the PFO) of clot from the greater saphenous vein. The patient underwent emergency saphenofemoral disconnection with femoral vein thrombectomy and subsequently carotid artery thrombectomy under general anesthesia. No carotid atheromatous wall lesions were detected at surgical exploration; no immunologic pathology, hypercoagulable status, or malignancy were recorded. No hemorrhagic cerebral complications were observed in the postoperative period, and the patient had an improvement of her neurologic status (a reduction of the National Institutes of Health Stroke Scale score from 7 to 3). Her recovery was uneventful. The patient was transferred for rehabilitation on postoperative day 5 with oral anticoagulation. Six-month ultrasound follow-up revealed deep and superficial venous system and carotid artery patency. The patient was asymptomatic and anticoagulation was discontinued. Paradoxical cerebral embolization through a PFO is a rare phenomenon that, in our patient, appeared to have resulted in stroke caused by a free-floating thrombus in the ICA. Accurate evaluation of carotid and lower limb veins by duplex scan is mandatory in cases of stroke of unknown origin, and urgent surgical repair can be useful in order to improve the clinical outcome.