Abdominal aortic aneurysms with short proximal neck: comparison between standard endograft and open repair.

AIM: Comparing the results of the treatment of abdominal aortic aneurysms (AAA) with infra-renal neck length ≤1 cm with open repair (OR) and with endovascular treatment (EVAR) with standard endograft. METHODS: Patients treated from January 2005 to December 2009 for infra-renal AAA with neck length ≤1 cm, were prospectively included. The choice of treatment was made up on anatomical and clinical criteria. Cases treated with OR (G1) and EVAR (G2) were compared. Primary end-points were: peri-operative mortality/morbidity and re-interventions, renal function worsening at discharge, mortality and re-interventions during follow-up. Secondary end points were: procedure time, need and time of intensive unit care (IUC) hospitalization, need for blood transfusions and hospital days. The comparison between groups was estimated by the Long-rank test. RESULTS: Eighty-two patients were treated (76 males and 6 females); the mean age was 71.4 years (range 56-86) and the mean AAA diameter was 6.2 cm. Forty-four patients were enrolled in G1 and 38 in G2. The two groups were clinically homogeneous, except for: age (G1

Spinal cord ischemia after endovascular treatment of infrarenal aortic aneurysm. Case report and literature review.

Spinal cord ischemia is a rare but catastrophic complication after endovascular treatment of infrarenal aortic aneurysm: only 14 cases are reported in the literature. A patient with a 6 cm infrarenal aortic aneurysm extending to both common iliac arteries and high surgical risk was submitted to endovascular repair with exclusion of both hypogastric arteries and surgical revascularization of the right hypogastric artery. The patient presented paraplegia, apallesthesia and superficial hyposensitivity immediately after the procedure. A spinal cord drainage was positioned with little improvement of superficial sensitivity. We undertook a systematic review of the literature on this topic.

Ring-stents supported infrarenal aortic endograft fits well in abdominal aortic aneurysms with tortuous anatomy.

AIM: Abdominal aortic aneurysms (AAA) with severe angulation of the neck or of the iliac arteries are often unsuitable for endovascular repair with conventional endografts. We evaluated the performance of a ring-stent abdominal endograft (AnacondaTM Vascutek, Terumo, Scotland) in a consecutive series of infrarenal AAA. METHODS: Preoperative, procedural and follow-up data of patients treated with AnacondaTM endograft between September 2005 and September 2009 were prospectively enrolled. Patients were divided in Group A (proximal neck angle > or =60 degrees or iliac arteries angle > or =90 degrees ) and Group B (all others). Main endpoints were technical and clinical success (primary and assisted) and late outcome in the two groups. Results were compared by Kaplan-Meier life table analysis with log-rank test (Mantel-Cox). RESULTS: One hundred twenty-seven patients, with a mean age of 73.5+/-6.9 years, have been included in this series. Mean aneurysm size was 56.7+/-10.4 mm. A severe angulation of the proximal aortic neck or/and of the iliac arteries was present in 44 cases (Group A), absent in 83 cases (Group B). The mean follow-up was 18.2+/-16.3 months. Overall primary technical success was achieved in 100% of the patients. At twenty-four months survival, primary and assisted clinical success were 94.2%, 88.2% and 91.3% in Group A and 80.3%, 83.7% and 95.2% in Group B respectively. No significant differences were found between the two groups. The only factor significantly associated with decreased survival was preoperative renal insufficiency. Iliac limb patency 24 months after EVAR in severely and non-severely angulated iliac axis was 96.7% and 98.1% respectively, with no significant difference between the groups. Only one proximal type I endoleak was detected in a patient with severe angulation of proximal aortic neck. No significant correlation between proximal type I endoleak and severe neck angulation was found. CONCLUSION: Aneurysms with severe neck or iliac arteries angulation can be treated by a ring-stent endograft with results similar to those of AAA with more favourable anatomy.

Preliminary results of Anaconda aortic endografts: a single center study.

OBJECTIVE: To evaluate the peri-operative results of Anaconda endograft in the first 49 cases treated in a single centre. METHODS: The study was carried out prospectively on cases of infrarenal abdominal aortic aneurysm (AAA) treated with Anaconda endograft. The characteristics of the proximal aortic neck and of the iliac access vessels were considered. The following operative results were assessed: the main body oversizing, the need to correct the positioning of the main body, the use of iliac extensions, the use of ballooning, the covering of patent hypogastric arteries, the presence of endoleaks and the need for conversion. Peri-operative (30 days) mortality and morbidity were also considered. RESULTS: Of the 49 cases treated, 44 were males with a mean age of 73 years (range: 55-89 yrs; SD+/-7 yrs). The mean diameter of the AAA was 56 mm (range 45-91 mm; SD+/-11); 4 cases had common iliac aneurysms with a diameter >3 cm. The mean neck diameter and length were 23 mm (range 19-28 mm; SD+/-3) and 25 mm (range 15-50 mm; SD+/-10) respectively. An aortic neck angle between 40 degrees and 70 degrees was present in 10 cases (20%) (mean 58 degrees; SD+/-15 degrees), and 20 cases (41%) had iliac tortuosity with an angle greater than 60 degrees (mean 85 degrees; SD+/-25 degrees). There were no cases of conversion or intra-operative death. One (2%) peri-operative death occurred, for reasons not related to the endograft. There were two cases of iliac limb thrombosis. CT at one month showed 12 cases (25%) of type II endoleak. There were no cases of type I or type III endoleaks. CONCLUSIONS: The preliminary data of this series demonstrates that the Anaconda endograft has good peri-operative results in the treatment of infrarenal AAAs with a neck length not less than 15 mm.

Common carotid agenesis and internal carotid stenting.

Agenesis of common carotid artery is rare and no report of stenting procedures (carotid artery stenting) for associated stenosis of the internal carotid have been published. We report a case of internal carotid stenosis associated with this anomaly. A 73-year-old male with left internal carotid artery originating from the arch, with significant stenosis, was referred to us. Wallstent was deployed with success. Carotid artery stenting should be reserved to uncomplicated arch anatomy and plaques with low fragmentation risk.

Endovascular and hybrid treatment of recurrent thoracoabdominal aneurysms in an HIV-positive patient.

INTRODUCTION: We report a case of staged endovascular and hybrid treatment of recurrent thoracoabdominal aneurysms (TAAA) in a 55-year-old HIV-positive man. REPORT: A patient, who had previously been surgically treated for a type III TAAA, presented with recurrent aneurysms. The patient was treated by a combination of endovascular and open surgery. Neither visceral nor spinal ischemia were observed. CONCLUSION: The hybrid treatment of recurrent TAAA could offer lower mortality and morbidity. Patients with HIV/AIDS treated for aortic aneurysms require close follow-up.

Fresh and cryopreserved arterial homografts: immunological and clinical results.

INTRODUCTION: This prospective study defined the immunological and clinical results after fresh and cryopreserved arterial homograft replacement due to graft infection. MATERIALS AND METHODS: Thirty patients who underwent ABO-compatible homograft transplantation were studied for anti-human leukocyte antigen (HLA): antibody production and CD3- and CD4- versus CD8-positive lymphocyte subsets. Nine patients (30%) received immunosuppressive treatment with cyclosporine (1 to 3 mg/kg/d). Immunological studies were performed preoperatively, and early (1, 3, 7 days) and late (1, 3, 6, 12, 24, 36, 48 months) during follow-up. Abdominal computed tomography scans were performed postoperatively at 1, 6, 12, 24, 36, and 48 months of follow-up. RESULTS: Preoperatively, antibodies were not detected. Postoperatively, a progressive increase in percent panel reactive antibodies was observed in all patients 1 month after the transplant. There were no difference between fresh and cryopreserved homografts. The antibody response among patients treated with cyclosporine was less pronounced and delayed. Recipient antibodies were directed against donor-specific antigens. During the immediate postoperative period (1, 3, 7 days) there was a slight increase in CD3- and CD4-positive T lymphocytes and a concomitant decrease in the CD8 subset. Later, CD3 and CD4 progressively decreased and the CD8 set increased. Clinically, no patients had signs of recurrent infection upon late follow-up. Four patients died (13%), but only one death was homograft-related (rupture of the graft). At 2-year follow-up, two patients showed stenotic lesions due to chronic rejection. Clinically, no differences were noted between fresh and cryopreserved homografts, or between patients treated with or without cyclosporine. CONCLUSIONS: Fresh and cryopreserved arterial homografts are immunogenic; they induce a strong anti-HLA antibody response, similar to chronic rejection.

Antilymphocyte globulin, cyclosporine, prednisolone, and granulocyte colony-stimulating factor for severe aplastic anemia: an update of the GITMO/EBMT study on 100 patients. European Group for Blood and Marrow Transplantation (EBMT) Working Party on Severe Aplastic Anemia and the Gruppo Italiano Trapianti di Midolio Osseo (GITMO).

One hundred consecutive patients with severe aplastic anemia (SAA) received horse antilymphocyte globulin (ALG), cyclosporin A (CyA), 6-methylprednisolone (6Mpred), and granulocyte colony-stimulating factor (G-CSF) as first-line therapy. The median age was 16 years (range, 1-72 years) and median neutrophil count was 0.2 x 10(9)/L (range, 0-0.5 x 10(9)/L). Trilineage hematologic recovery (at a median interval of 96 days from treatment) was seen in 77 patients (48 complete, 29 partial) after 1 (n = 50) or more courses of ALG (n = 27). Of the 23 nonresponders, 11 patients died at a median interval of 83 days (range, 16-1132 days), 6 were considered treatment failures and underwent transplantation, and 6 were pancytopenic. Cytogenetic abnormalities were seen in 11% of patients, clonal hematologic disease in 8%, and relapse of marrow aplasia in 9%. The actuarial survival at 5 years was 87% (median follow-up 1424 days): 76% versus 98% for patients with neutrophil counts less than versus greater than 0.2 x 10(9)/L (P =.001) and 88% versus 87% for patients aged less than versus more than 16 years (P =.8). The actuarial probability of discontinuing CyA was 38%. Patients who did not achieve a white blood cell (WBC) count of 5 x 10(9)/L during G-CSF treatment have a low probability of responding (37%) and a high mortality rate (42%). This update confirms a high probability for SAA patients of becoming transfusion independent and of surviving after treatment with ALG, CyA, 6Mpred, and G-CSF, with a significant effect of neutrophil counts on outcome. Problems still remain, such as absent or incomplete responses, clonal evolution, relapse of the original disease, and cyclosporine dependence. Early transplantation, also from alternative donors, may be warranted in patients with poor WBC response to G-CSF. (Blood. 2000;95:1931-1934)