Safety, Effectiveness and Pitfalls of Carbon Dioxide Routine Use as a Contrast Agent for Endovascular Abdominal Aortic Repair.

BACKGROUND: Despite the evidence of good performance, carbon dioxide (CO2) routine employment as a contrast agent for endovascular procedures is far from being adopted with its use currently limited to patients with renal impairment and known allergy to iodinated contrast medium (ICM). The purpose of our study is to evaluate the safety and effectiveness of CO2 guided endovascular abdominal aortic aneurysm repair (EVAR) in a standard population and to assess the rationale for a future widespread use. METHODS: We retrospectively collected data of every patient who underwent CO2 guided standard EVAR from September 2020 to May 2021 and compared them with the data of every patient who underwent EVAR using ICM from December 2019 to August 2020 in our unit. The selection of the contrast medium was not based on any preoperative factor as the contrast medium was routinely used in every patient in both periods. The primary end point of the study was the technical success rate. Secondary end points were the early and late complication rates, radiation exposure and renal function impairment. RESULTS: 49 patients underwent ICM guided EVAR and 52 patients underwent CO2 guided EVAR in our unit in the time frames specified above. The technical success rate was 100% in both groups with no accidental coverage of any target vessel. Intraoperative endoleaks were observed in 14% of ICM patients and 25% of CO2 patients. The radiation exposure was higher in the CO2 group if compared to the ICM group (311.48 vs. 159.86 median mGy/cm2 - P < 0.001). The incidence of postoperative acute kidney injury was low and similar in the 2 groups. No significant worsening over time of the renal function has been reported in both groups. CONCLUSIONS: EVAR can be safely performed under CO2 guidance without the integration of any quantity of ICM but with an increase in radiation exposure. The nephroprotective role of CO2 guided EVAR in a standard population is unclear and the same role in renal impaired patients should be validated with further studies on selected populations.

Multicenter Comparison of Aortic Arch Aneurysms and Dissections Zone 0 Hybrid and Total Endovascular Repair.

PURPOSE: Comparison of hybrid and total endovascular aortic arch repair at two tertiary vascular surgery centers. MATERIALS AND METHODS: Consecutive patients undergoing hybrid (HG) or total endovascular (TEG) total aortic arch repair for aneurysms or dissections were included (2008-2022). Primary outcome measure was 30-day mortality. Secondary outcomes were major complications, technical success (defined as absence of surgical conversion/mortality, high-flow endoleaks or branch/limb occlusion), clinical success (defined as absence of disabling clinical sequelae), late and aortic-related mortality/reinterventions, freedom from endoleaks, aortic diameter growth > 5 mm, graft migration and supra-aortic trunks (SAT) patency. RESULTS: In total, 30 patients were included, 17 in HG and 13 in TEG. TEG presented shorter intervention time (240.5 vs 341 min, p = 0.01), median ICU stay (1 vs 4.5 days, p < 0.01) and median length of stay (8 vs 17.5 days, p < 0.01). No intraoperative deaths occurred. Technical success was 100%; clinical success was 70.6% in HG and 100% in TEG (p = 0.05). Thirty-day mortality was 13.3%, exclusively in HG (p = 0.11). Nine major complications occurred in 8 patients, 5 in HG and 3 in TEG (p = 0.99), among which five strokes, two in HG and three in TEG (p = 0.62). Late mortality was 38.5%, six patients in HG and four in TEG, p = 0.6. Two late aortic-related deaths occurred in HG (p = 0.9). Two aortic-related reinterventions, no graft migration or SAT occlusion was observed. CONCLUSIONS: Total endovascular repair seems to shorten operative times and provide higher clinical success compared with hybrid solutions, without significant 30-day mortality differences. The most common major complication is stroke.

First Case of Nellix Stent Rupture in a Huge Symptomatic Abdominal Aortic Aneurysm Who Underwent Endovascular Aneurysm Sealing 7 Years Before.

PURPOSE: Despite encouraging early results, mid- and long-term follow-up of endovascular aneurysm sealing (EVAS) has shown increased rates of failure mainly associated with endoleak detection and progressive bag separation with aneurysm reperfusion. CASE REPORT: We present the first case of a Nellix endograft stent fracture detected in a 91-year-old male patient, presenting with widespread abdominal pain, 7 years after elective treatment of an abdominal aortic aneurysm by EVAS. Considering the sudden and unexpected nature of the event, an in-depth analysis of the possible causes of this structural failure has been performed. CONCLUSION: Material fatigue could be another significant cause of late EVAS failure and should be carefully assessed in addition to endoleak detection during follow-up. CLINICAL IMPACT: The case presented in this article further underlines the importance of a strict long term follow-up protocol in every patients who underwent EVAS.

Management of Nellix migration and type Ia endoleak from proximal endovascular aneurysm sealing relining to late open conversion.

BACKGROUND: Despite promising early results, midterm failures of the Nellix endovascular aneurysm sealing (EVAS) system (Endologix Inc, Irvine, Calif) have been reported at higher than expected rates. The management of proximal endoleaks and migration differs from those after conventional endovascular aortic aneurysm repair (EVAR) owing to the peculiar design of the Nellix device. In the present study, we report a monocentric experience in the management of EVAS complications using various techniques. We also performed a comprehensive review of the relevant literature on both open surgical and endovascular management of proximal failure of EVAS from the MEDLINE database. METHODS: We retrospectively analyzed the reinterventions for type Ia endoleak and migration after elective infrarenal EVAS at our institution. We collected preoperative, intraoperative, and follow-up data. Open and endovascular techniques are described. Overall survival, aortic-related mortality, and the technical success rate (rate of exclusion of endoleaks) with endovascular techniques were the primary outcomes. RESULTS: We performed 101 infrarenal elective EVAS procedures from 2013 to 2018. Of the 101 patients, 20 (19.8%) had required reintervention for proximal sealing failure. The indications were type Ia (Is2, Is3) endoleak, migration >5 mm, sac expansion >5 mm, and secondary rupture. Of the 20 patients, 6 (30%) were treated with endovascular techniques-2 with a chimney Nellix-in-Nellix application and 4 with proximal relining with a covered stent. The remaining 14 patients (70%) were treated with late open conversion (OC). The average time from EVAS to reintervention was 36.1 months (range, 3-65 months). Six patients (30%) had undergone OC in an emergent setting because of secondary rupture. The technical success rate for the patients treated with endovascular reinterventions was 100%. The 30-day mortality was 20% (4 of 20), all emergent cases (four of six emergent repairs; 67%). The overall survival for the 20 patients was 75% (n = 15) at a mean follow-up of 15.1 months (range, 2-47 months). One patient had died after 7 months of non-aortic-related causes. CONCLUSIONS: The high reintervention rate of the Nellix graft mandates careful evaluation for its further use with the revised instructions for use, and it should not be used off-label. OC remains the strategy of choice when managing Nellix proximal sealing failures in fit patients. Chimney Nellix-in-Nellix application and transcatheter embolization are feasible alternative techniques. Proximal relining also appears to be an effective alternative to more complex interventions, although it requires further studies for validation.

Long-term failure after endovascular aneurysm sealing in a real-life, single-center experience with the Nellix endograft.

BACKGROUND: Endovascular aneurysm sealing (EVAS) is an innovative alternative to conventional endovascular aneurysm repair (EVAR). EVAS relies on sac anchoring without proximal fixation to achieve sealing and should have allowed for the treatment of a broader range of anatomic features compared with standard EVAR. Despite the encouraging early reports, the mid- and long-term follow-up data have shown increased rates of failure. To address the issue, the manufacturer introduced revised instructions for use (IFU) in 2016. The present study reports the outcomes of this system after a median follow-up of 45 months. METHODS: Data for all patients electively treated with EVAS at our institution were retrospectively collected. The patients were retrospectively reclassified according to the 2016 revised IFU of the device. All patients in the present series had undergone EVAS for the treatment of infrarenal abdominal aortic aneurysms (AAAs). The primary end point was therapeutic failure: graft migration >5 mm, sac expansion >5 mm, type IA endoleak (Is2 and Is3 using the Van den Ham classification), type Ib endoleak, and secondary rupture. The overall mortality, aortic-related mortality, and reintervention rates were also analyzed. RESULTS: A total of 101 patients had undergone elective treatment by EVAS from 2013 to 2018 for infrarenal AAAs. The median follow-up was 3.75 years. Therapeutic failure was observed in 31 of the 101 patients (30.7%), with no significant difference between the in-IFU and off-IFU 2016 subgroups. Failure occurred at a median interval of 34 months from the index procedure. Of the 101 patients, 6.9% had presented with secondary rupture. Freedom from aneurysm-related mortality was 96.9% at 1 and 2 years and 89.9% at 5 years. Freedom from reintervention decreased over time: 94.7% at 1 year, 77% at 4 years, and 52.1% at 6 years. Of the 101 patients, 14 (13.9%) had undergone emergent or elective graft explantation. CONCLUSIONS: EVAS performed worse than conventional endografts for several critical end points, regardless of any preoperative anatomic parameters. The incidence of therapeutic failures tended to increase over time, especially 4 years after the index procedure.

Retrograde Use of Gore Hybrid Vascular Graft for a Complex Carotid Tandem Lesion.

BACKGROUND: Successful treatment of tandem lesions of carotid arteries may represent a challenging goal for the vascular specialist. In the "endovascular era," a hybrid approach may represent a viable option. CASE REPORT: We describe the case of a 65-year-old patient with severe postcarotid endarterectomy recurrent stenosis of the internal carotid artery (ICA) associated with primitive stenosis of the proximal common carotid artery (CCA) treated with retrograde stenting and carotid bypass using the Gore Hybrid Vascular Graft (GHVG). CONCLUSIONS: We demonstrated the effectiveness of the hybrid technique using GHVG in treating carotid tandem lesions involving CCA and ICA.

Extra-Anatomic Revascularization of Extensive Coral Reef Aorta.

BACKGROUND: Coral reef aorta (CRA) is a rare, potential lethal disease of the visceral aorta as it can cause visceral and renal infarction. Various surgical approaches have been proposed for the CRA treatment. The purpose of this article is to report different extensive extra-anatomic CRA treatment modalities tailored on the patients' clinical and anatomic presentation. METHODS: From April 2006 to October 2012, 4 symptomatic patients with extensive CRA were treated at our department. Extra-anatomic aortic revascularization with selective visceral vessels clamping was performed in all cases. RESULTS: Technical success was 100%. No perioperative death was registered. All patients remained asymptomatic during the follow-up period (62, 49, 25, and 94 months, respectively), with bypasses and target vessels patency. CONCLUSIONS: The extra-anatomic bypass with selective visceral vessels clamping reduces the aortic occlusion time and the risk of organ ischemia. All approaches available should be considered on a case-by-case basis and in high-volume centers.

Proximal Embolic Protection Devices in Complicated Carotid Artery Stenting.

The most frequent complication during carotid artery stenting (CAS) is intraoperative distal embolization. Three categories of embolic protection devices (EPDs) are routinely used through a transfemoral or transcervical approach: distal occlusion devices, distal EPDs with flow preservation using filters, and the proximal occlusive protective systems. We report the case of the internal carotid artery (ICA) plaque rupture during CAS using a proximal EPD (the Mo.Ma system; INVATEC), treated with immediate surgery. The proximal occlusive protective system permitted the common carotid artery and ICA endoclamping for the time necessary to prepare the patient for the carotid endarterectomy. The EPDs should always be chosen considering the patient's and lesion's characteristics. This knowledge allows their use even as "bridge" endovascular devices.

Acute kidney injury after open and endovascular elective repair for infrarenal abdominal aortic aneurysms.

OBJECTIVE: The aim of this study was to evaluate the incidence of acute kidney injury (AKI) after open and endovascular abdominal aortic aneurysm repair according to the Aneurysm Renal Injury Score classification. METHODS: We retrospectively evaluated 431 patients undergoing elective open aortic repair (OAR; n = 285) or endovascular repair (n = 146) for infrarenal aortic aneurysm. All data regarding preoperative and postoperative serum creatinine concentrations and postoperative outcomes were assessed. Univariate and multivariate logistic regression models investigated the association between AKI and different risk factors and complications. RESULTS: The incidence of AKI was significantly higher after OAR (26.3% vs 5.5%; P < .001). A significant share of patients who experienced AKI were restored to preoperative renal function at discharge (62.5% vs 77.5% in the endovascular and OAR groups, respectively; P = .37). Preoperative serum creatinine concentration was significantly higher in those patients who further developed AKI (1.25 vs 1.04 mg/dL; P < .001). At the multivariate analysis, AKI was significantly associated with current smoking (odds ratio [OR], 2.05; 95% confidence interval [CI], 1.19-3.52; P = .01), hypertension (OR, 2.46; 95% CI, 1.21-4.3; P = .01), chronic renal disease (OR, 2.53; 95% CI, 1.42-4.53; P < .001), OAR (OR, 7.3; 95% CI, 3.25-16.42; P < .001), and arrhythmias (OR, 3.16; 95% CI, 1.09-9.13; P = .03). AKI stage did not affect postoperative outcomes, except for a longer hospital stay in patients in stage 2 and stage 3 compared with stage 1. CONCLUSIONS: AKI is a common but often reversible complication, especially after OAR. There is an urgent need of a common classification for AKI after aortic surgery. New diagnostic markers for AKI should be evaluated in large-scale studies to assess their reliability.

Contrast-Enhanced Sonographic Follow-up After Stenting of Visceral Artery Aneurysms.

We report 2 cases of exclusion of visceral artery aneurysms. The first was a common hepatic artery aneurysm treated with a multilayer stent; the second was a celiac trunk aneurysm excluded by a covered stent. Computed tomographic angiography was performed at regular intervals after each procedure, together with echo color Doppler imaging and contrast-enhanced sonography. Computed tomographic angiography and contrast-enhanced sonography were able to detect endoleaks in both patients and the related inflow vessel; moreover, diameter measurements of the sacs were identical. In our preliminary experience, contrast-enhanced sonography appeared to be as accurate as computed tomographic angiography after endovascular visceral artery aneurysm exclusion.

Mediastinoscopy-assisted Treatment of an Aberrant Right Subclavian Artery.

Aberrant right subclavian artery (ARSA) is a rare congenital anomaly characterized by the origin of the right subclavian artery from the aortic arch distally to the left subclavian artery. We describe the case of a young patient with symptomatic ARSA treated by mediastinoscopy-assisted ligation at its origin and subclavian-carotid transposition.

Open Surgical Treatment of a Severe Case of Obstructive Calcifying Aortic Disease.

The obstructive calcifying aortic disease refers to severe calcifications of the descending aorta that obstruct or slow blood flow. Here, we report the case of a 65-year-old woman with recent onset of a very tight intermittent claudication and concomitant severe and uncontrolled hypertension, treated with a bypass graft between the proximal descending thoracic aorta and the supravisceral abdominal aorta.

Use of Contrast-Enhanced Ultrasound in Carotid Atherosclerotic Disease: Limits and Perspectives.

Contrast-enhanced ultrasound (CEUS) has recently become one of the most versatile and powerful diagnostic tools in vascular surgery. One of the most interesting fields of application of this technique is the study of the carotid atherosclerotic plaque vascularization and its correlation with neurological symptoms (transient ischemic attack, minor stroke, and major stroke) and with the characteristics of the "vulnerable plaque" (surface ulceration, hypoechoic plaques, intraplaque hemorrhage, thinner fibrous cap, and carotid plaque neovascularization at histopathological analysis of the sample after surgical removal). The purpose of this review is to collect all the original studies available in literature (24 studies with 1356 patients enrolled) and to discuss the state of the art, limits, and future perspectives of CEUS analysis. The results of this work confirm the reliability of this imaging study for the detection of plaques with high risk of embolization; however, a shared, user-friendly protocol of imaging analysis is not available yet. The definition of this operative protocol becomes mandatory in order to compare results from different centers and to validate a cerebrovascular risk stratification of the carotid atherosclerotic lesions evaluated with CEUS.

Contrast-enhanced ultrasound to predict the risk of microembolization during carotid artery stenting.

OBJECTIVES: Cerebral microembolization, one of the most frequent complications of carotid artery stenting, is associated with an increased risk of peri- and post-procedural stroke and transient ischemic attack and a mid-term risk of neurocognitive decline. A valuable tool to evaluate carotid plaque instability and risk of embolization is contrast-enhanced ultrasound. With this prospective study we sought to determine the correlation between contrast enhancement of the plaque and cerebral microembolization after carotid stent deployment and to evaluate the clinical impact of the neurological injury. MATERIALS AND METHODS: Thirty-five consecutive patients with carotid artery stenosis and indications for endovascular stenting were enrolled. Before the procedure, patients were evaluated with contrast-enhanced ultrasound to define plaque enhancement (signal intensity). All endovascular procedures were performed under cerebral filter protection. Diffusion-weighted magnetic resonance imaging scans to detect microemboli were obtained before and 48 h after the stent deployment. The Ray auditory verbal learning test to assess neurocognitive function was administered before and 1 month after the procedure. RESULTS: Nineteen patients (54 %) developed new cerebral ischemic lesions after carotid artery stenting. Contrast enhancement of the plaque was greater in the patients with post-procedural microembolization than in those without it [maximum signal intensity 26 ± 7.7 vs. 21 ± 5.2, respectively, (p = 0.039), mean signal intensity, 20.7 ± 6.1 vs. 16.5 ± 5.3, respectively (p = 0.048)]. No correlation was found between neurocognitive test scores and microembolization or plaque enhancement. CONCLUSION: Contrast enhancement of the carotid plaque is strongly associated with post-procedural microembolization and for this reason it can be considered a reliable tool for an accurate selection of patients undergoing this endovascular treatment. However, the neurocognitive test scores performed in this study are not enough sensible to appreciate the impact of the neurological injury on the day life activities.

Successful management with 2 overlapping bare stents for post-carotid endarterectomy carotid pseudoaneurysm secondary to carotid shunt.

Pseudoaneurysms are a rare complication of carotid endarterectomy. We successfully excluded with 2 overlapping bare stents a distal carotid artery pseudoaneurysm very likely induced by a Pruitt-Inahara shunt 2 months after carotid endarterectomy.

Rupture of giant superficial femoral artery aneurysm in a leukemic patient submitted to chemotherapy.

The superficial femoral artery (SFA) is a relatively rare location for lower limb aneurysmatic disease. In the literature, this disease is described an association between a relatively high growth rate and/or the rupture of aneurysms and chemotherapeutic agents. We report a case of the rupture of a giant SFA aneurysm in a patient during chemotherapy for acute lymphatic leukemia.

Pulmonary embolism due to popliteal vein aneurysm during pregnancy induced by in vitro fertilization.

Popliteal vein aneurysms (PVAs) are rare but may cause severe and even fatal complications, such as pulmonary embolism (PE). A woman at the eighth week of pregnancy came to our attention because of a thrombosis of a previously undetected left PVA, diagnosed after a PE episode. Surgery was delayed until after delivery and breastfeeding, during which anticoagulant therapy was established.

Aneurysm of the aberrant right subclavian artery: surgical and hybrid repair of two cases in a single center.

The aberrant right subclavian artery (ARSA) aneurysm is rare; however, the risk of rupture and thromboembolism is high, with a postrupture mortality rate of 50%. In this report, we have described two cases of this anomaly. In the first case, a 62-year-old male patient presented with a symptomatic aneurysm of ARSA (maximum diameter of 4 cm) causing chest pain with dyspnea during moderate physical effort. Surgical treatment was performed with aneurysmal exclusion and direct anastomosis of the two heads of the subclavian artery. In the second case, a 72-year-old male patient presented with a symptomatic aneurysm (maximum diameter of 5.1 cm) of ARSA causing dysphagia and dysphonia. In this case, a one-stage hybrid treatment was performed: a bilateral carotid-subclavian bypass was associated with intentional occlusion of both subclavian arteries (by plug positioning) during thoracic endovascular stent-grafting procedures. In both cases, the peri/postoperative course was uneventful and the technical results in our series were excellent at long-term follow-up. Surgical treatment can be safely performed in patients with low operative risk or whenever endovascular technique is not suitable. The ARSA aneurysm, with appropriate anatomy, can be successfully treated by hybrid treatment (combined surgical and endovascular approach). We reckon that this minimally invasive technique helps avoid thoracotomy and could be the treatment of choice in high-risk patients.