Open Repair for Juxtarenal Aortic Aneurysm: Short and Long-term Results.

BACKGROUND: The recent technological evolution has also allowed for the treatment of juxtarenal aortic aneurysm (JAA) with an endovascular technique, but short- and long-term results must be compared with the results of open treatment, which is the gold standard. In this study, we analyzed the short- and long-term results of open surgical treatment (open repair) in patients with JAA in our series. METHODS: From January 2006 to December 2016, 155 patients were treated for JAA with open repair; the data were analyzed retrospectively. The mean age was 71.17 years (standard deviation [SD] 7.1), and mean size of aneurysm was 6.15 cm (SD 1.1). The ASA classes 2, 3, and 4 were 20%, 74% and 6%, respectively. Follow-up included clinical visit and abdominal aorta Duplex scan after 1 and 6 months and annually. The mean follow-up interval was 48.6 (SD 32.4) months. RESULTS: The mean surgical time was 256 min (SD 69), the mean stay in the intensive care unit was 1.6 days (SD 1.2), and the mean total hospital stay was 10.2 days (SD 4.3). Aortic cross-clamping was usually suprarenal (110, 71%); in 39 (25%), the aortic clamping was between the renal arteries, and 6 patients (4%) required a supraceliac cross-clamping. The mean renal ischemia time due to aortic clamping was 17 min (SD 3.5). In 32 patients (21%), the left renal vein was sectioned for performing proximal aortic anastomosis and then reconstructed. Twelve patients (8%) required a renal revascularization, and in 49 patients (32%), an hypogastric bypass was performed. The 30-day mortality rate was 0.6%, and only 1 patient died in the postoperative due to intestinal infarction. The postoperative morbidities occurred in 15 cases (10%). Six patients had dehiscence of the laparotomy without the involvement of the muscle, 4 patients had an asymptomatic small increase of the troponin, and in 3 patients, there was an increase in creatinine >1.8 mg/dL. No dialysis was performed. Two patients had peripheral embolism in the lower limbs. Twenty-six patients (15%) died in the follow-up, but causes have never been related to aortic disease. CONCLUSIONS: Open repair of JAA is still safe, effective, and durable also in the long-term period and even in patients with multiple cardiovascular risk factors.

Surgical treatment for pseudo-occlusion of the internal carotid artery.

OBJECTIVES: Carotid artery pseudo-occlusion is a rare condition and its natural history and clinicopathological characteristics are not well defined. We reported our 7-year experience in the surgical treatment of carotid artery pseudo-occlusion to determine the real benefit of the surgical option. METHODS: From January 2006 to December 2013, 1414 patients were treated for high-grade stenosis of the internal carotid artery, 33 (2.3%) presented with a carotid pseudo-occlusion (26 males and 7 females, mean age: 70 ± 10). Nineteen patients were symptomatic, and 14 asymptomatic. Carotid artery pseudo-occlusion was identified by duplex scan (segmental occlusion at the origin of internal carotid artery with very thin distal flow) and the diagnostic confirmation was obtained by angio-computed-tomography (CT) scan. The operation was performed under general anaesthesia and constant Electroencephalography (EEG) monitoring. The follow-up was performed by duplex scan at discharge, 30 days, 6 months and yearly. RESULTS: Politetrafluoroetilene (PTFE) patch endarterectomy, eversion endarterectomy and carotid bypass were performed in 20 (61%), 10 (30%) and 3 patients (9%), respectively. No mortality or stroke was observed in postoperative period. Four patients presented with an asymptomatic postoperative thrombosis of the internal carotid artery. No restenosis was observed. CONCLUSIONS: Surgical treatment for carotid artery pseudo-occlusion is safe and effective.

Surgery for acute lower limb ischemia in the elderly population: results of a comparative study.

BACKGROUND: To evaluate the outcome of surgical treatment of acute lower limb ischemia in elderly patients. The primary endpoints were early and midterm rates of survival and limb salvage. METHODS: A retrospective analysis involving 76 consecutive patients observed for acute lower limb ischemia between March 2005 and December 2008 who underwent revascularization was conducted. A total of 44 patients (group A) of age >80 years (average age: 86.9 ± 4.5 years; 13 men and 31 women) had a site of obstruction at the level of abdominal aorta in one case (2.3%), common-external iliac artery/common femoral artery in 15 (34.1%), superficial femoral artery/popliteal artery in 26 (59.1%), and infrapopliteal arteries in two (4.5%), and embolectomy, thrombectomy, bypass, and angioplasty was performed in 24 (54.5%), 11 (25.0%), eight (18.2%), and one (2.3%) case(s), respectively. A total of 32 patients (group B) of age <80 years (average age: 67.2 ± 12.2 years; 19 men and 13 women) with an analogous site of obstruction at the level of abdominal aorta in one case (3.1%), common/external iliac artery/common femoral artery in 12 (37.5%), superficial femoral artery/popliteal artery in three (9.4%), and infrapopliteal arteries in 16 (50.0%) underwent the same aforementioned procedures in 10 (31.3%), 12 (37.5%), nine (28.1%), and one (3.1%) case(s), respectively. RESULTS: At 30 days after surgery, survival and limb salvage were both 93.2% in group A versus 96.9% and 87.5%, respectively, in group B, whereas they were 93.2% and 65.8%, respectively, in group A versus 85.7% and 96.9%, respectively, in group B (p = 0.22 and p = 0.19, respectively) at the midterm control. The univariate and multivariate analyses showed that category 2b of acute ischemia (immediately-threatening) has a negative statistically significant influence on the survival rate (p = 0.01). CONCLUSIONS: Limb salvage rates after surgical intervention for acute lower limb ischemia in the elderly population are comparable with those of the younger population, whereas survival rates are lower, but without statistical significance. The only factor that negatively influences the survival rate is the 2b clinical category of acute ischemia, regardless of the age of the patient.

Intrasac fibrin glue injection after platinum coils placement: the efficacy of a simple intraoperative procedure in preventing type II endoleak after endovascular aneurysm repair.

OBJECTIVES: To verify in our experience if fibrin glue injection into the aneurysm sac, made at the end of endovascular aneurysm repair (EVAR), can reduce type II endoleak rates. METHODS: Between January 2005 and February 2008, 38 patients underwent EVAR for an unruptured abdominal aortic aneurysm. The first 20 consecutive patients (Group A) had standard EVAR while the last 18 patients (Group B) had EVAR with fibrin glue injection into the sac, regardless of type II endoleak's presence. RESULTS: There was no statistically significant difference between the two groups concerning the surgical time and the time of X-ray exposure (P=0.30 and 0.54, respectively). Type II endoleak rate was significantly higher in Group A compared to Group B (6 cases, 30% vs. 1 case, 5.5%, respectively, P=0.05). Primary short-term clinical success was 95% and 100%, respectively. At 12 months, selective lumbar embolization was performed in two patients in Group A and in one patient in Group B. Patients in Group A had less computed tomography (CT) studies than patients in Group B (2.0 vs. 1.2, respectively, P=0.024). CONCLUSIONS: Fibrin glue injection is a safe procedure and seems to reduce type II endoleak rates. Patients who received this procedure had fewer CT examinations, with reduced health-care costs.

Hypogastric artery bypass in open repair of abdominal aortoiliac aneurysm: a safe procedure.

OBJECTIVES: The aim of this study is to assess the immediate and mid-term results of hypogastric artery bypass (HAB) in open repair of abdominal aortic aneurysm (AAA). METHODS: The clinical data of 24 patients with an average age of 70.4 years [standard deviation (S.D.)+/-8.1 years] with AAA treated between January 2005 and December 2008 with HAB during open repair of aortoiliac aneurysm were reviewed. Eighteen patients received unilateral and six bilateral hypogastric bypasses, using a segment of Dacron graft prosthesis. Concomitant hypogastric eversion endarterectomy was associated in six cases (25%). Follow-up was complete in all the 24 patients and averaged 16.2 months (range 1-35). Postoperative imaging protocol involved a conventional Echocolordoppler and CT-scan. With respect to the operating time, the blood loss, the intensive care unit (ICU) and the length of ward admission (LWA) stay, we compared the 24 patients who underwent hypogastric bypass (group A) with the 50 patients who had bifurcated graft without hypogastric bypass (group B). RESULTS: Between the two groups, statistically different results were demonstrated only with respect to the duration of operation (h) (group A 5.19+/-1.38 vs. group B 4.39+/-1.32, P=0.0195). No statistical differences were noted for ICU stay (h) (group A median 21.50 vs. group B median 21.3, range 1 degrees -3 degrees quartile 19.75-23.50) and LWA stay (days) (group A median 8.50, range 1 degrees -3 degrees quartile 7.00-11.50 vs. group B median 8.0, range 1 degrees -3 degrees quartile 7.00-9.00). There were no operative deaths, bowel or intestinal ischemia in the early postoperative period between the two groups. In group A, one patient had transient renal failure and one patient had an acute coronary syndrome. In group B, one patient had a peripheral ischemia who required tibioperoneal embolectomy. The patency of the hypogastric grafts was demonstrated in all cases. CONCLUSIONS: In our experience, direct revascularization of the hypogastric artery to ensure pelvic vascularization in aortoiliac surgery appears a safe procedure.