Total aortic arch endovascular repair using an iliac branch device.

A 76-year-old man who 2 years before underwent thoracic endovascular aortic repair for aneurysm of the aortic arch was admitted to our department with dysphonia and dysphagia due to an increasing diameter of aneurysm of the aortic arch because of type Ia endoleak. To obtain an adequate proximal neck for conventional thoracic endovascular aortic repair, the double chimney graft technique was chosen using a hypogastric component of the iliac branch Excluder (W. L. Gore & Associates, Flagstaff, Ariz) for the anonymous trunk. At 1-year follow-up, computed tomography scan showed patent chimney graft and no endoleaks. This is the first report in the literature using a hypogastric branch in the aortic arch.

Spinal cord ischemia after simultaneous and sequential treatment of multilevel aortic disease.

OBJECTIVES: The aim of the present study is to report a risk analysis for spinal cord injury in a recent cohort of patients with simultaneous and sequential treatment of multilevel aortic disease. METHODS: We performed a multicenter study with a retrospective data analysis. Simultaneous treatment refers to descending thoracic and infrarenal aortic lesions treated during the same operation, and sequential treatment refers to separate operations. All descending replacements were managed with endovascular repair. RESULTS: Of 4320 patients, multilevel aortic disease was detected in 77 (1.8%). Simultaneous repair was performed in 32 patients (41.5%), and a sequential repair was performed in 45 patients (58.4%). Postoperative spinal cord injury developed in 6 patients (7.8%). At multivariable analysis, the distance of the distal aortic neck from the celiac trunk was the only independent predictor of postoperative spinal cord injury (odds ratio, 0.75; 95% confidence interval, 0.56-0.99; P=.046); open surgical repair of the abdominal aortic disease was associated with a higher risk of spinal cord injury but did not reach statistical significance (odds ratio, 0.16; 95% confidence interval, 0.02-1.06; P=.057). Actuarial survival estimates at 1, 2, and 5 years after the procedure were 80%±5%, 68%±6%, and 63%±7%, respectively. Spinal cord injury did not impair survival (P=.885). CONCLUSIONS: In our experience, the risk of spinal cord injury is still substantial at 8% in patients with multilevel aortic disease. The distance of the distal landing zone from the celiac trunk is a significant predictor of spinal cord ischemia.

Comparison of precuffed expanded polytetrafluorothylene and heparin-bonded polytetrafluorothylene graft in crural bypass.

BACKGROUND: The purpose of this study was to evaluate early and midterm results of tibial bypasses comparing precuffed expanded polytetrafluoroethylene (PTFE) graft (Distaflo) and heparin-bonded PTFE graft (Propaten) with a distal vein patch. METHODS: This is a retrospective cohort analysis evaluating patients who underwent PTFE femorocrural bypasses between April 2004 and December 2010 at the Vascular Surgery Division of the Poliambulanza Foundation Hospital (Brescia, Italy). Results were analyzed in terms of primary and secondary graft patency, limb salvage, and survival with univariate (Kaplan-Meier curves and log-rank test) and multivariate (Cox regression) analyses. RESULTS: After analyzing many patients, we found 79 femorotibial bypass PTFE grafts. We used a Propaten graft and vein patch in 40 patients and a Distaflo graft in 39 patients. The two groups were comparable for main risk factors, except for age. Indication for surgical revascularization was critical limb ischemia in all patients. In 54 cases (68%), it was a redo bypass because of a previously failed revascularization. Perioperative mortality within 30 days from intervention was 2.5%, whereas overall mortality during follow-up was 29%, with a 36-month survival rate of 58% (95% confidence interval [CI]: 0.44-0.77) on life table analysis. We observed a significant difference between two groups in terms of survival at 36 months (Propaten: 0.84 [95% CI: 0.69-1]; Distaflo: 0.21 [95% CI: 0.07-0.63]; P < 0.001; 95% CI: 0.07-0.63; odds ratio [OR]: 0.21). At 24 months, the two groups (Propaten vs. Distaflo) were equivalent in terms of primary patency (Propaten: 0.33 [95% CI: 0.21-0.53]; Distaflo: 0.47 [95% CI: 0.32-0.70]; P = 0.793), secondary patency (Propaten: 0.36 [95% CI: 0.23-0.57]; Distaflo: 0.49 [95% CI: 0.33-0.72]; P = 0.855), and limb salvage (Propaten: 0.65 [95% CI: 0.51-0.84]; Distaflo: 0.57 [95% CI: 0.41-0.79]; P = 0.18). At Cox regression analysis, age of >80 years (P < 0.04; 95% CI: 0.23-0.95; OR: 0.47), peroneal artery distal anastomosis (P < 0.04; 95% CI: 1.04-5.62; OR: 2.42), simultaneous adjunctive procedures (P < 0.02; 95% CI: 1.21-17.74; OR: 4.64), and redo bypass (P < 0.05; 95% CI: 1-6.26; OR: 2.5) were associated with long-term poorer primary patency rates. Postoperative treatment with warfarin therapy compared with antiplatelet therapy was independently associated with better secondary patency (P < 0.04; 95% CI: 0.20-0.95; OR: 0.44) and limb salvage (P < 0.03; 95% CI: 0.11-0.87; OR: 0.32) rates. CONCLUSIONS: Distaflo and Propaten with a distal vein patch in our experience have similar patency and limb salvage results, although further randomized and larger studies are necessary. Postoperative anticoagulation therapy seems better than antiplatelet therapy in terms of patency and limb salvage rate.

Predictors and outcomes of acute kidney injury after thoracic aortic endograft repair.

BACKGROUND: This study analyzed the incidence and the predictive factors of postoperative acute kidney injury (AKI) after thoracic endovascular aortic repair (TEVAR) and evaluated the effect of AKI on postoperative survival. METHODS: Between November 2000 and April 2011, all consecutive patients undergoing TEVAR of the descending thoracic or thoracoabdominal aorta were enrolled at four teaching hospitals. Estimated glomerular filtration rate (eGFR) was evaluated during the entire hospitalization. AKI was defined by the RIFLE (Risk, Injury, Failure, Loss of function, End-stage renal disease) consensus criteria. RESULTS: The study included 171 patients (80% men) who were a mean age of 69±14 years (range, 18-87 years). AKI occurred in 24 patients (14%). Independent predictors of postoperative AKI were preoperative depressed eGFR, thoracoabdominal extent, and postoperative transfusion. Patients with AKI experienced major postoperative complications (P=.001), longer hospitalization (P=.008), and higher hospital mortality (29% vs 4%; P<.001). Kaplan-Meier analysis showed a survival of 82%, 51%, and 51% at 1, 3, and 5 years for patients who developed AKI, which was significantly worse than the 99%, 89%, and 80% for patients who did not experience AKI (P=.001). CONCLUSIONS: Preoperative poor renal function, blood transfusions, and the thoracoabdominal extent of the aortic disease were the most important predictors for AKI.

Fate of popliteal artery aneurysms after exclusion and bypass.

BACKGROUND: Treatment of popliteal aneurysm (PA) includes exclusion and bypass graft. In excluded sac, persistent flow through collateral arteries (endoleak) could result in aneurysm growth. METHODS: We retrospectively reviewed PA treated by exclusion and bypass, using duplex ultrasound or computed tomography (CT) scans to demonstrate the presence of residual flow and sac growth. RESULTS: Between 1997 and 2007, we treated 53 PAs in 46 patients by ligation and bypass grafting using polytetrafuoroethylene (PTFE) or saphenous vein. The mean PA diameter preoperatively was 33.4 mm (range, 20-70 mm). At a mean follow-up period of 35 months, 75% (n = 40) PA showed a decrease in mean transverse diameter, from 33.4 to 27.3 mm (p < 0.001). In 17% patients (n = 9), aneurysm sac size remained unchanged, whereas in 8% (n = 4) it increased (mean, 4.5 mm). In six cases (11%), persistent sac flow was revealed by Duplex or TC scan. One patient with a large aneurysm that increased by 50% underwent endoaneurysmorrhaphy through a posterior approach because of symptoms related to local compression. No rupture occurred in follow-up period. The cumulative Kaplan-Meier patency rate at 12, 36, and 60 months were 86%, 76%, and 69%, respectively. Limb salvage rate at 5 years was 92%. Cumulative patency rate at 60 months in the group with popliteal artery unchanged or increased resulted significantly lower than the group with aneurismal sac decreased (30% vs. 84%; p < 0.001). Multivariate analysis did not show correlation between risk factors or preoperative aneurysm diameter, and increased or decreased sac size. CONCLUSIONS: In our results, aneurysm sac growth exists but is low, and a persistent sac flow was not correlated to increased sac size. In view of these results, we believe that medial approach for popliteal artery reconstruction can be used because the aneurysm increase is low and the risk of rupture is not important. No decrease of sac size was otherwise significantly correlated to graft patency.

Endovascular repair of a ruptured abdominal aortic aneurysm in a patient with unfavorable anatomy.

Endovascular repair of an abdominal aortic aneurysm (AAA) offers hope of improved outcomes in patients presenting with acute rupture. However, a high proportion of such patients have unfavorable proximal neck anatomy and are not suitable for treatment with conventional endografts. In this case report, the authors describe a successful endovascular repair of a ruptured AAA with very short and angulated proximal neck.

Endovascular treatment of a symptomatic carotid artery aneurysm with a stent graft.

Endovascular methods have become more widespread and offer an alternative to surgery, which is often difficult in case of a hostile neck resulting from radiotherapy. Carotid pseudoaneurysm after laryngectomy is a very uncommon complication. We report a case of symptomatic carotid artery pseudoaneurysm treated using a stent graft.

Home therapy with LMWH in deep vein thrombosis: randomized study comparing single and double daily administrations.

The aim of this study was to assess the effectiveness of low-molecular-weight heparin (LMWH) treatment of deep vein thrombosis (DVT) in terms of the evolution of thrombosis, the incidence of adverse events, and compliance with heparin treatment using 2 types of LMWH available on the market administered in therapeutic doses throughout the period of treatment (Nadroparin) or at therapeutic doses only during the first month of treatment followed by a prophylactic phase at half dose (Parnaparin). A randomized prospective study was carried out on patients under observation with a recent diagnosis of DVT. The objectives of the study were to confirm the effectiveness of therapy with LMWH in terms of prevention of the risk of thromboembolism, of relapse of DVT, and of hemorrhagic complications, and to complete an evaluation of venous recanalization and residual valve competence in the 2 groups of patients. From December 2002 to June 2005, we randomized a total of 91 patients (51 in the Parnaparin group and 40 in the Nadroparin group). Overall, there was 1 case of nonfatal pulmonary embolism (1.1%) at 7 days into therapy with LMWH. There were 3 cases (3.3%) of progression of thrombosis despite therapy with LMWH, 2 cases (5%) in the Nadroparin group, and 1 case (2%) in the Parnaparin group (P = NS), and after suspension of the therapy, there was 1 case of relapse of thrombosis. Three of the 4 thrombotic events occurred in patients with active neoplasia. Moreover, only 1 major hemorrhagic event (1.1%) required blood transfusion. The Doppler ultrasound in the follow-up showed a complete resolution of 56% of the vein thromboses at an average of 6.1 +/- 4.6 (mean +/- SD) months. Valve competence recovered in 65.9% of cases with no significant difference between the 2 heparin groups. Home treatment of sural and femoral-popliteal DVT using LMWH represents a safe and effective method in the prevention of pulmonary embolism and encourages the process of recanalization of the thrombosed vessel, especially in cases of sural and/or popliteal DVT. Administration can be carried out with the same degree of safety at the therapeutic dose throughout the period of treatment or can be halved after the first month of treatment. In patients with active neoplasia, treatment with oral anticoagulant therapy must be considered.

Routine shunting is a safe and reliable method of cerebral protection during carotid endarterectomy.

The purpose of this report is to describe the perioperative and long-term outcomes of standard carotid endarterectomy (CEA) with general anesthesia, routine shunting, and patching and to show that routine shunting is a safe and reliable method of cerebral protection. Between January 1998 and December 2004, 700 patients attending our Department of Vascular Surgery underwent 786 CEAs performed using a standardized technique. Forty-four patients were excluded from the analysis because they underwent combined CEA and coronary artery bypass grafting, so the analysis is based on the results of 742 CEAs in 656 patients (86 bilateral CEAs). The strict surgical protocol included general anesthesia and standard carotid bifurcation endarterectomy with routine shunting (Javid's shunt) and Dacron patching. The Javid shunts were easily inserted in 738 cases (99.4%) but could not be used in four cases (0.5%) because of the presence of a very small internal carotid artery. The mean ischemic time required to insert the shunt and complete the suture was 4.7 min (+/-1.15), and the mean time to perform the endarterectomy was 34.3 min (+/-6.7). The mean follow-up was 24.4 months (+/-17.3). Overall 30-day mortality was 0.1% (one patient) due to a contralateral major stroke. The 1-month perioperative neurological complication rate was 0.7%, with three major and two minor strokes. The cumulative stroke and death rate was 0.8%. Preoperative symptoms such as hypertension, contralateral occlusion, or an age of more than 80 years were not independent risk factors for perioperative stroke. In the long-term follow-up, Kaplan-Meier analysis indicated an estimated 5-year stroke-free rate of 98.0%. There were eight cases (1%) of >70% restenosis (four cases) or thrombosis (four cases) of the operated internal carotid artery during the follow-up in asymptomatic patients: in four cases, carotid stenting due to >70% restenosis led to good results. The Kaplan-Meier estimate of the restenosis-free rate was 97.8%. The combined stroke and mortality rate of 0.8%, and the restenosis rate of 1% support the argument that standard CEA performed with routine shunting as brain protection leads to excellent early and long-term results.

Compression repair versus low-dose thrombin injection for the treatment of iatrogenic femoral pseudoaneurysm: a retrospective case-control study.

BACKGROUND: It has been shown that thrombin injection is a safe and effective technique for the treatment of iatrogenic femoral pseudoaneurysm. The aim of this study was to evaluate and compare the use of ultrasound-guided low-dose thrombin injections with ultrasonographically-guided compression repair in the treatment of iatrogenic femoral arterial pseudoaneurysm. METHODS: We compared two cohorts of patients treated for iatrogenic femoral pseudoaneurysm: the first included 38 patients who underwent ultrasonographically-guided compression repair as a first-step approach between January 1998 and November 2002; the second included 21 patients treated with ultrasound-guided low-dose thrombin injection between December 2002 and December 2003. RESULTS: Both groups had similar demographic characteristics and aneurysm sizes (p = 0.72). Compression was successful in 24/38 patients (63%); the 14 persistent aneurysms were surgically repaired (37%). The primary thrombin injection of a mean dose of 185+/-95 U/ml (range 100-400 U/ml) successfully obliterated all of the 21 pseudoaneurysms (success rate 100 vs 63% in the compression group, p = 0.004). Thrombosis occurred within an average of 12+/-15 s of thrombin injection. Sedation was used in 42% of the patients undergoing compression and in none of those receiving thrombin (p = 0.001). The duration of hospitalization was significantly longer in patients undergoing compression therapy (9.8+/-5.6 vs 5.6+/-1.4 days, p = 0.001). CONCLUSIONS: Ultrasound-guided low-dose thrombin injection appears to be more effective in reducing the need for surgical repair when used to treat iatrogenic femoral pseudoaneurysm, is better tolerated by the patients, and requires a shorter hospital stay.

Pancreaticoduodenal artery aneurysms associated with celiac axis occlusion.

True aneurysms of the pancreaticoduodenal artery associated with celiac axis occlusion are very rare; only 38 cases have been reported, according to our literature review. We present three consecutive cases with different options of surgical treatment.

Endovascular treatment of a symptomatic aneurysm of the left subclavian artery.

Upper extremity ischemia is a rare entity usually due to emboli of arterial origin. Such thromboemboli produce acute symptoms of sufficient severity as to necessitate early surgical intervention. We report the case of a patient with severe ischemia in his left hand, in whom the embolic source was a mural thrombus localized at the level of a saccular aneurysm of the subclavian artery. After having excluded the presence of a thoracic outlet syndrome, the lesion was successfully treated by means of percutaneous implantation of a stent graft with the exclusion of the aneurysm and the sealing of the thrombus.