Late Neck Related Adverse Events are Rare Among Patients with Wide Aortic Neck Undergoing Endovascular Aneurysm Repair with the Ovation Endograft.

BACKGROUND: Patients with wide aortic necks undergoing Endovascular Aneurysm Repair (EVAR) have been shown to be at a higher risk for neck-related complications. We aim to examine outcomes of EVAR with an endograft exerting minimal outward pressure (Ovation-Endologix) in patients with a large baseline neck diameter. METHODS: We performed a retrospective single center study, including consecutive patients undergoing EVAR with the Ovation system from May 2011 to April 2021. Patients were divided in Groups 1 and 2 if the 20, 23, 26, 29 mm or the 34 mm proximal diameter main body was used, respectively. According to the instructions for use of the device, for neck diameters 27-30 mm the 34 mm main body is required. Primary endpoint was rate of neck related complications during follow-up, (type Ia endoleak, migration >10 mm and neck-related re-interventions) and rate of aortic neck dilatation (AND). AND was determined based on multiple aortic neck diameters that were recorded and compared between the 1-month computed tomography angiography (CTA) after EVAR and the last available follow-up CTA.Secondary endpoints were peri-procedural and follow-up outcomes such as endoleaks, reinterventions and overall mortality. RESULTS: In total 281 patients were included, 222 in Group 1 and 59 in Group 2. Patients in Group 2 presented significantly shorter neck length, higher neck angulation and more common reversed tapered configuration. Median follow-up was 36 months (Range: 6-106). Early and late type Ia endoleak was observed in 4 and 2 patients in each group, respectively (P = 0.063 and P = 0.195, respectively). Distal migration was observed in 2 patients in Group 2 and AND was recorded in 2 patients in each group (P = 0.195). Freedom from the primary endpoint was estimated at 98%, 94%, 94% at 12-, 36-, 60-months for Group 1 and at 98%, 95%, 86% for Group 2 (P-Value 0.266). Probability of survival was 95%, 86%, 75% at 12-, 36-, 60-months for Group 1 and 83%, 77%, 72% for Group 2 (P-Value 0.226).Multivariate regression analysis identified neither Group 1 versus Group 2 nor absolute value of aortic neck diameter as significant predictors of neck-related adverse events. Neck diameters did not display significant differences over time in any of the levels evaluated. CONCLUSIONS: EVAR with the Ovation endograft results in low rates of late neck related complications which is also true for patients with wide baseline aortic necks.

Multiple Sites of Arterial Thrombosis in A 35-Year Old Patient after ChAdOx1 (AstraZeneca) Vaccination, Requiring Emergent Femoral and Carotid Surgical Thrombectomy.

BACKGROUND: Vaccine Induced Thrombotic Thrombocytopenia (VITT) is a rare complication following ChAdOx1 (AstraZeneca) vaccination. Venous thrombosis in unusual sites such as splachnic or intracranial thrombosis, is the commonest manifestation. CASE REPORT: We report a 35-year-old male patient who presented with acute left leg ischemia and thrombocytopenia 11-days after vaccination requiring emergent thrombectomy. During work-up, a localized thrombus was detected in the left carotid bifurcation mandating carotid thrombectomy. Localized right iliac thrombus causing a non-limiting flow stenosis was treated conservatively. The platelet aggregating capacity of patient's plasma was confirmed in a functional assay, thereby establishing VITT. CONCLUSION: To the best of our knowledge this is the first case presenting multiple arterial thromboses requiring surgical treatment after ChAdOx1 vaccination.

Complexity-based local diagnostic reference levels (DRLs) for standard endovascular aneurysm repair (EVAR) procedures.

PURPOSE: The aim of this study was to establish complexity-based local diagnostic reference levels (DRLs) for standard endovascular aneurysm repair (EVAR) procedures. METHODS: Dosimetric data for 73 consecutive patients were collected prospectively. All procedures were performed on a Siemens Axiom Artis FA angiographic unit (Siemens, Erlangen, Germany). Fluoroscopy time (FT), dose area product (DAP), air kerma (Ka.r) at reference point as well as patient's age, height and weight were recorded for each procedure. Moreover, the complexity level of each procedure was evaluated. Spearman rank correlation tests were used to evaluate the degree of association between variables. RESULTS: 2nd quartiles of DAP for low, medium and high complexity standard EVAR procedures were 144.2 Gycm2, 160.1 Gycm2 and 189.5 Gycm2respectively. The median DAP of the full sample was 153.2 Gycm2. Statistical analysis showed a strong correlation between BMI and DAP (r = 0.68, p-value < 0.0001) and a moderate correlation between BMI and Ka.r (r = 0.52, p-value < 0.0001). Furthermore, a strong correlation was found between Ka.r and FT (r = 0.76, p-value < 0.0001) and a moderate correlation was found between DAP and FT (r = 0.57, p-value < 0.0001). CONCLUSION: The complexity of an EVAR procedure is associated with the total burden of radiation. Establishment of complexity-based DRLs for interventional radiology procedures can contribute to the radiation protection of patients and staff.

Paraoxonase-1 and Symptomatic Status in Carotid Artery Disease.

BACKGROUND: Paraoxonase-1 (PON-1) is a high-density lipoprotein (HDL)-associated hydrolase that appears to have a protective action against atherosclerosis. The aim of our study is to identify whether PON-1 levels may be associated with the manifestation of symptoms in patients with carotid artery stenosis. METHODS: We studied all patients who underwent carotid endarterectomy in the Vascular Surgery Department of Laikon Hospital, Athens, Greece, from July 2012 to July 2014. Medical history was recorded and PON-1 glucose, total cholesterol, HDL cholesterol, low-density lipoprotein cholesterol, and triglycerides levels were measured. Variables were compared between symptomatic and asymptomatic patients. A receiver operating characteristic (ROC) curve was constructed to evaluate the accuracy of PON-1 to predict symptoms. RESULTS: A total of 74 patients were included, 41 were asymptomatic and the mean age was 68.5 years. The 2 groups appear to differ significantly with regards to the PON-1 levels, with the symptomatic group showing lower levels (5.3 ± 1.19 vs. 4.6 ± 1.36 ng/mL; P = 0.025). ROC analysis demonstrated an area under the curve of 0.654 (P = 0.023). CONCLUSIONS: Reduced PON-1 levels showed a significant association with symptomatic status, which was independent of other traditional cardiovascular factors. Further studies are required to prospectively assess the role of PON-1 in predicting cerebrovascular events in patients with carotid artery disease.

In Situ Composite Homograft Utilizing the Femoral Vein and the Occluded Superficial Femoral Artery after Eversion Endarterectomy for the Management of an Iliofemoral Synthetic Graft Infection.

Aortic or iliac graft infection is a serious complication in vascular surgery, which carries significant risks for the patient's limb and life and requires complex treatment. We report a patient who presented sepsis due to a previous ilio(common iliac)-femoral(profunda femoris) graft infection. Taking into account that the superficial femoral and popliteal arteries were occluded (no suitable target vessel, except for the distal profunda femoral) and the fact that he presented methicillin-resistant Staphylococcus aureus-positive blood cultures, the patient was scheduled for excision of the contaminated graft and in situ reconstruction. Along with the femoral vein, a segment of the adjacent occluded superficial femoral artery was used after eversion endarterectomy to ensure adequate homograft length to perform the bypass. To our knowledge, this is the first report of this technique which can be particularly useful in similar settings.

Analysis of Echocardiographic Markers and Pulse Wave Velocities in a Patient Who Developed New Cardiac Symptoms after Implantation of an Aortic Endograft.

Increased arterial stiffness has been related to altered cardiovascular hemodynamics, left ventricular hypertrophy, and a higher risk for cardiac events. Pulse wave velocity (PWV) has been used as a surrogate marker for arterial stiffness. Treatment of abdominal aortic aneurysms (AAAs) involves insertion of a rigid graft or endograft inside the arterial system which has been shown to increase arterial stiffness, but the cardiac implications of these alterations are mostly unknown. We report a case of a patient with a previous AAA surgical repair (>10 years ago) who developed a para-anastomotic pseudoaneurysm which was excluded with implantation of an endoluminal graft. From a cardiac perspective, this patient was asymptomatic and had a normal baseline preoperative evaluation. He had an initially high PWV (17 m/sec). Postprocedurally, the patient developed cardiac symptoms, and he underwent coronary angiography which indicated significant coronary artery disease, and he subsequently underwent bypass grafting. One week after the endovascular repair, the patient presented with an increased PWV at 21 m/sec. Echocardiographic indices were mostly unaltered (ejection fraction, left ventricular mass index, and left atrium volume index) compared with the preoperative evaluation, except for the global longitudinal strain which deteriorated from -25 to -21%. This case provides insight into hemodynamic alterations after implantation of an endograft which may result in deterioration of asymptomatic heart disease.

The Use of the Profunda Femoral Artery as the Sole Target Vessel to Bypass Aortoiliac Disease in Patients with Critical Limb Ischemia and Concomitant Unreconstructable Infrainguinal Disease.

BACKGROUND: Critical limb ischemia (CLI) often results from multilevel occlusive disease. There are occasions where a patent profunda femoral artery (PFA) is the only target artery that can be used as outflow during reconstruction to bypass aortoiliac disease (AOID), with no further option for infrainguinal revascularization. We aim to report results of the use of PFA as the sole target vessel for the treatment of these patients. METHODS: This is a retrospective, single-center study including CLI patients treated during 36 months. All procedures were included regardless of inflow site. The outcomes examined were hemodynamic improvement, clinical status change, amputation-free and overall survival, and patency of the prosthesis. Univariate analysis was performed to identify possible predictors of adverse outcomes. RESULTS: Twenty-three patients and 27 limbs were included (2 female, mean age 70.6). Sixteen limbs presented rest pain and 11 tissue loss. Inflow was obtained from the axillary (n = 9), contralateral femoral (n = 8), abdominal aorta (n = 2), thoracic aorta (n = 1), ipsilateral external iliac (n = 2), and contralateral external iliac artery (n = 1). Immediately postoperatively ankle-brachial index significantly increased from 0.15 (0-0.5) to 0.50 (0.25-0.9), (P-value < 0.001). Twenty-four limbs presented clinical improvement (3 minimally, 18 moderately, and 3 markedly improved) and 3 presented no change. During a mean follow-up of 15.8 (2-36) months, we recorded 4 deaths and 4 major amputations. Mean predicted overall survival and amputation-free survival were 29.8 (95% confidence interval [CI] 24.5-35.1) and 26.5 months (95% CI 21.1-31.8), respectively. Predicted primary patency was 76% at 3 years. Univariate analysis revealed significant associations only between bypass patency and limp loss (P-value = 0.021). CONCLUSIONS: In the presence of CLI due to AOID and unreconstructable infrainguinal disease, the use of PFA as the sole target vessel during bypass is associated with significant rates of clinical improvement and limb salvage.

Acute aortic occlusion due to tumor embolism in a patient with lung malignancy.

OBJECTIVES: Acute lower limb ischemia caused by tumor embolization is rare, despite the fact that cancer is a common cause of hypercoagulability predisposing to venous thrombosis. Arterial embolization is mostly associated with intracardiac tumors while lung malignancies are the second most common cause of tumor embolism. METHODS: In this report, we present a male patient who developed acute bilateral lower limb ischemia in the immediate postoperative period after a thoracotomy for attempted left upper lobe resection for lung cancer. RESULTS: The patient was treated with a subclavian-bifemoral bypass, since an initial attempted embolectomy was unsuccessful. Histopathological characteristics of thrombus obtained during embolectomy were consistent with the histopathology of the primary tumor. CONCLUSION: Acute ischemia is an emergency that should be diagnosed and treated immediately. Interestingly, in this case, the presence of epidural anesthesia masked the initial symptoms and delayed diagnosis. Preoperative assessment with transesophageal echocardiography may reveal patients at high risk for tumor embolism.

Routine use of an aortic balloon to resolve possible inflow stenosis induced by the inflatable ring fixation mechanism of the Ovation endograft.

PURPOSE: To investigate if the routine use of an aortic balloon within 15-30 min after Ovation stent graft ring inflation would resolve any inflow stenosis, which may reach 60 %, at the level of the sealing rings. Moreover, we estimated the potential hemodynamic compromise in these patients during rest and exercise. METHODS: Following 3-dimensional reconstruction of AAA models, cross-sectional area of the infrarenal aorta just proximal the sealing mechanism (A aort, R aort, respectively) and internal area at the site of stenosis (A int, R int, respectively) were measured for 83. Forty-nine patients were managed without and 34 with an aortic balloon use. Pressure drop during rest and exercise was estimated. RESULTS: Technical success was 98 % and there were no perioperative deaths, one type-I endoleak, and 12 (14.5 %) type-II endoleaks. Median A int and R int were significantly reduced compared to A aort [55 % reduction, 143 (range 28-380) mm2 vs 314 (range 177-531) mm2, P value <0.001] and R aort [42 % reduction, 6.75 (range 3-11) mm vs 10 (range 7.5-13) mm, P value <0.001]. The observed stenosis was significantly less for patients in whom an aortic balloon was used intraoperatively (area reduction 36 vs 59 %, P value = 0.009). This stenosis caused a statistically significant, but clinically insignificant ΔP in both groups during rest (0.13 vs 0.06 mmHg, P value = 0.02) and exercise (1 vs 0.5 mmHg, P value = 0.02). CONCLUSION: The advantages of the unique sealing mechanism of the Ovation device seem to be accompanied by an inflow stenosis which is significantly reduced when neck molding with an aortic balloon is used. Overall, the hemodynamic impact of this abnormality seems to be clinically insignificant at 1-month follow-up.

Advances in determining abdominal aortic aneurysm size and growth.

Abdominal aortic aneurysm is a common pathology in the aging population of the developed world which carries a significant mortality in excess of 80% in case of rupture. Aneurysmal disease probably represents the only surgical condition in which size is such a critical determinant of the need for intervention and therefore the ability to accurately and reproducibly record aneurysm size and growth over time is of outmost importance. In the same time that imaging techniques may be limited by intra- and inter-observer variability and there may be inconsistencies due to different modalities [ultrasound, computed tomography (CT)], rapid technologic advancement have taken aortic imaging to the next level. Digital imaging, multi-detector scanners, thin slice CT and most- importantly the ability to perform 3-dimensional reconstruction and image post-processing have currently become widely available rendering most of the imaging modalities used in the past out of date. The aim of the current article is to report on various imaging methods and current state of the art techniques used to record aneurysm size and growth. Moreover we aim to emphasize on the future research directions and report on techniques which probably will be widely used and incorporated in clinical practice in the near future.

Late renal artery occlusion following endovascular repair of abdominal aortic aneurysm: a possible complication of mural thrombus formation within aortic endografts.

Mural thrombus formation within aortic endoprostheses has been described to occur in up to one-third of aortic endografts depending on the device type. Data regarding the clinical significance of such a phenomenon are scarce, but in most cases it is considered to be clinically innocent. The authors describe a rare case of late renal artery occlusion due to intraprosthetic thrombus formation and extension into the right renal orifice 30 months after endovascular abdominal aortic aneurysm repair. Additionally, a brief literature review regarding the incidence and natural history of mural thrombotic deposits within aortic endografts is also conducted.

Treatment paradigms for ductus arteriosus aneurysms in adults.

We report two symptomatic cases of ductus arteriosus aneurysm (DDA) in adults treated in our department over a 5-years period. One patient underwent an open off-pump surgical procedure, while the second one was treated with partial aortic arch debranching and endovascular stent-grafting. DDA in adults is an uncommon condition and can present with rupture, hoarseness or symptoms of airway obstruction. Although indications for intervention are not clearly established, most authors advocate that DDAs should be treated regardless of their size, to avoid the risk of rupture, while others reserve intervention for symptomatic patients. We report on the management of these patients and provide an updated review of the current literature.

Late open conversion after failed endovascular aortic aneurysm repair.

OBJECTIVE: Endovascular aortic aneurysm repair (EVAR) is widely used for the treatment of abdominal aortic aneurysms. Complications secondary to EVAR are also treated with endovascular techniques. When this is not applicable, open surgical repair is mandatory. This study aims to present our experience in open surgical repair after failed EVAR. METHODS: Within the period from 2004 through 2013, 18 patients (17 men; mean age, 73.9 years) were operated on because of EVAR failure due to persistent type II endoleak (n = 10), type I or III endoleak (n = 3), mixed-type endoleaks (n = 2), stent graft thrombosis (n = 2), and aortoenteric fistulae (n = 1). Stent grafts used for EVAR were Zenith (n = 8), Talent (n = 4), Excluder (n = 4), and Anaconda (n = 2). RESULTS: Mean time interval between EVAR and open conversion was 36 months (range, 2-120 months). Fifteen (83.3%) operations were elective, and three (16.7%) were urgent due to aneurysm rupture (n = 2) and aortoenteric fistula (n = 1). Six (33.3%) patients with type II endoleak were treated with simple ligation of the culprit vessels, without aortic clamping and stent graft explantation. In six (33.3%) patients, the stent graft was partially removed except from the segment attached to the proximal neck, while in five (27.8%) patients, complete removal of the stent graft was necessary. Finally, in one patient, with type III endoleak, a hybrid endovascular and open repair was performed. Clamping of the aorta was necessary in 12 (66.7%) patients (infrarenal, n = 10 or suprarenal, n = 2). Overall operative mortality was 5.6%. Postoperative complications included one abdominal wall defect requiring surgical revision and paroxysmal atrial fibrillation both in the same patient, and one case of pulmonary infection, requiring prolonged intubation and intensive care unit stay for 6 days. CONCLUSIONS: Late open conversion after failed EVAR remains challenging. Avoidance of aortic cross-clamping and if possible, partial or total preservation of the stent graft may improve outcomes in terms of operative mortality and morbidity. Elective operations seem to be associated with better outcomes, prompting thus for close follow-up of EVAR patients and early decision for conversion if other options are doubtful.

Multiple aneurysms of the inferior pancreaticoduodenal artery: a rare complication of acute pancreatitis.

Inferior pancreaticoduodenal artery (IPDA) aneurysms are uncommon, representing nearly 2% of all visceral aneurysms, and sporadically associated with celiac artery stenosis. Multiple IPDA aneurysms have been rarely reported. We report a case of a 53-year-old female patient with a history of prior pancreatitis, who presented with two IPDA aneurysms combined with median arcuate ligament-syndrome-like stenosis of the celiac trunk. The patient was treated successfully with coil embolization under local anesthesia. The procedure is described and illustrated in detail and the advantages and technical considerations of such an approach are also being discussed.

Management of a complicated ruptured infected pseudoaneurysm of the femoral artery in a drug addict.

Infected pseudoaneurysm of the femoral artery represents a devastating complication of intravenous drug abuse, especially in the event of rupture. Operative strategy depends upon the extent of arterial injury and the coexistence of infection or sepsis. Options range from simple common femoral artery (CFA) ligation to complex arterial reconstruction with autologous grafts (arterial, venous, or homografts). We report herein the management of a 29-year-old male patient who was urgently admitted with a ruptured pseudoaneurysm of the right CFA, extending well above the inguinal ligament. Multidisciplinary approach with multiple arterial reconstructions and subsequent coverage of the tissue defect with a rectus abdominis musculocutaneous flap transposition was performed.

Clinical manifestations of aortocaval fistulas in ruptured abdominal aortic aneurysm: report of two cases.

Aortocaval fistula (ACF) is an unusual complication of ruptured abdominal aortic aneurysm (AAA), involving less than 3-6% of all ruptured cases. The clinical presentation is often obscure, depending on the coexistence of retroperitoneal rupture and hemodynamic instability. Prompt preoperative diagnosis is essential in order to plan the operative approach and improve patient's outcome. We report the surgical treatment of two patients presented in the emergency department with ACF due to ruptured AAA, each with different clinical presentation, emphasizing the high index of suspicion needed by the clinician to early diagnose and treat this often lethal condition. Operative strategy and special considerations in the management of this subgroup of patients are also discussed.