Editor's Choice - Comparison of Renal Outcomes in Patients Treated by Zenith® Fenestrated and Zenith® Abdominal Aortic Aneurysm Stent grafts in US Prospective Pivotal Trials.

OBJECTIVE/BACKGROUND: Fenestrated endovascular repair (FEVAR) has been used to treat complex abdominal aortic aneurysms (AAAs). The risk of renal function deterioration compared with infrarenal endovascular aortic repair (EVAR) has not been determined. METHODS: Patients with preserved renal function (estimated glomerular filtration rate [eGFR] > 45 mL/minute) enrolled in two prospective, non-randomised studies evaluating Zenith fenestrated and AAA stent grafts were matched (1:2) by propensity scores for age, sex, hypertension, diabetes, and pre-operative eGFR. Sixty-seven patients were treated by FEVAR and 134 matched controls treated by EVAR. Mean follow-up was 30 ± 20 months. Outcomes included acute kidney injury (AKI) defined by RIFLE and changes in serum creatinine (sCr), eGFR, and chronic kidney disease (CKD) staging up to 5 years. RESULTS: AKI at 1 month was similar between groups, with > 25% decline in eGFR observed in 5% of FEVAR and 9% of EVAR patients (p = .39). There were no significant differences in > 25% decline in eGFR at 2 years (FEVAR 20% vs. EVAR 20%; p > .99) or 5 years (FEVAR 27% vs. EVAR 50%; p = .50). Progression to stage IV-V CKD was similar at 2 years (FEVAR 2% vs. EVAR 3%; p > .99) and 5 years (FEVAR 7% vs. EVAR 8%; p > .99), with similar sCr and eGFR up to 5 years. During follow-up, there were more renal artery stenosis/occlusions (15/67 [22%] vs. 3/134 [2%]; p < .001) and renal related re-interventions (12/67 [18%] vs. 4/134 [3%]; p < .001) in patients treated by FEVAR. Rate of progression to renal failure requiring dialysis was low and identical in both groups (1.5% vs. 1.5%; p > .99). CONCLUSION: Aortic repair with FEVAR and EVAR was associated with similar rates of renal function deterioration in patients with preserved pre-operative renal function. Renal related re-interventions were higher following FEVAR, although net changes in renal function were similar in both groups.

Endovascular treatment of visceral artery aneurysms.

Visceral artery aneurysms (VAAs) are a rare entity; however, aneurysm rupture can be a catastrophic complication, which may lead to a mortality rate up to 90%. With the advent of endovascular technology and rapid development of endovascular materials, tailored endovascular therapy including embolization and placement of stents or stent grafts according to clinical presentation, anatomy of the aneurysm, and downstream organ, has become a promising alternative to open surgery. This review article summarizes the current state-of-the-art on endovascular treatment of VAAs.

Stent-assisted remote iliac artery endarterectomy: an alternative approach to treating combined external iliac and common femoral artery disease.

OBJECTIVE: Stent-assisted remote iliac endarterectomy (SA-RIEA) is a hybrid minimally invasive technique for treating patients with combined external iliac and common femoral disease, when the only alternative would be conventional open revascularisation. DESIGN: This was a retrospective, single-centre study. MATERIALS AND METHODS: From January 2004 to April 2010, 155 SA-RIEA procedures were performed. The patients' mean age was 62 (range, 43-86) years. Indications for surgery were: severe claudication in 79 (51%), rest pain in 43 (28%) and gangrene in 33 (21%) cases. The mean length of follow-up was 21 months. RESULT: Initial technical success was achieved in 145 (93.5%) procedures. Ten patients required conversion to a conventional iliofemoral reconstructive procedure. The 1-, 3- and 5-year primary, primary-assisted and secondary patency rates were 80.2%, 74.7% and 69.3%; 84.8%, 82.4% and 78.2%; and 86.8%, 84.2% and 79.6%, respectively. Within the first 30 days, there were no early reocclusions, one (0.6%) perioperative death due to myocardial infarction, five (3.4%) minor wound complications and two (1.3%) limb losses. During follow-up, seven patients underwent open reconstruction due to symptomatic reocclusion, and four were re-operated on due to symptomatic restenosis (three percutaneous transluminal angioplasties (PTAs), one reendarterectomy). CONCLUSION: In patients with combined common femoral and external iliac disease, SA-RIEA appears to offer a safe and effective alternative to conventional open surgery.

Successful human vascular reconstructions with long-term refrigerated venous homografts.

Fresh autologous vein grafts are commonly used for infrainguinal vascular reconstructions with good results. Previously we have confirmed the high viability index of homografts even after long-term storage at 4 degrees C in tissue culture medium. In this clinical study, we have evaluated the in vivo efficiency of this storage method in humans with major peripheral graft infections. Between April 2006 and November 2008, data from patients who underwent graft excision and venous allograft reconstruction were collected prospectively (5 men, 2 women, mean age 68 years). Six patients had acute ischemia at the time of allograft reconstruction, while 3 had experienced anastomosis rupture. Allograft reconstruction was performed as an emergency procedure in 3 cases. The observed parameters included patient survival, limb salvage, persistence or recurrence of infection and allograft patency. In the follow-up period reoperation, excision or thrombectomy was necessary in 3 cases. There were no perioperative deaths, early amputations, persistent or recurrent infections. In conclusion, this study demonstrates the efficacy of long-term 4 degrees C storage of venous allografts for revascularization in cases with peripheral bypass graft infection. We suggest that this technique is a useful option for graft preservation and propose a wide-scale introduction.

Oxygen uptake kinetics during heavy submaximal exercise: Effect of sickle cell trait with or without alpha-thalassemia.

Sickle cell trait (SCT) is a genetic disease affecting the synthesis of normal hemoglobin (Hb) marked by the heterozygous presence of HbA and HbS. It is thought that exercise tolerance and aerobic capacity could be limited in SCT carriers, but that the co-existence of alpha-thalassemia with SCT (SCTAT) could improve exercise response. To examine these issues, we compared the characteristics of VO2 kinetics during a constant heavy exercise among athletes carrying either the SCT (n = 6), the SCTAT (n = 9), or the normal Hb (control group; n = 10). After determination of maximal power output (Ppeak), all subjects underwent a constant heavy cycling exercise lasting 9 min at approximately 70 % Ppeak. Pulmonary VO2 and cardio-respiratory parameters were measured breath-by-breath and the VO2 response was modelled using non-linear regression techniques. The time constant of the VO2 primary component and oxygen deficit were not significantly different among the three groups. The VO2 slow component was 28 % and 33 % higher (p < 0.05) in SCT and SCTAT than in the control groups, respectively. Altogether, athletes with the SCT and the SCTAT had higher heart rate at the beginning (+ 5.2 %) and the end (+ 7.4 %) of the slow component compared to the control group (p < 0.05). These results suggest that SCT and SCTAT subjects are not limited during the first exercise minutes, but are prone to exercise intolerance and to lower aerobic capacity thereafter, due to a higher VO2 slow component, and that alpha-thalassemia does not improve exercise response. The finding of a higher slow component in SCT and SCTAT athletes was possibly due to the loss of O2 availability to muscles, additional fiber recruitment and/or higher cardiac load with time.

[Treatment of pancreaticopleural fistulas]. / Behandlung pankreatiko-pleuraler Fisteln.

Pancreaticopleural fistulas are rare but serious complications of chronic or recurrent inflammatory pancreatic disease. Massive unilateral or bilateral pleural effusion may occur in association with rupture of pancreatic duct or pseudocyst into the pleural cavity. In the past decade we have treated 10 patients with pancreaticopleural fistulas. Eight of them had a previous history of inflammatory pancreatic disease. Diagnosis was made by finding a markedly elevated amylase level (10 pts) in the pleural fluid. US and CT examination enabled the establishment of the diagnosis of pancreatic origin, showing chronic pancreatic (9 pts) and pancreatic pseudocyst (6 pts). Pancreaticopleural fistula was successfully demonstrated by ERCP in four patients. Initial treatment was non-operative using total parenteral or jejunal nutrition and multiple thoracocentesis or thoracic drainage. Anti-secretory octreotide therapy was used in all patients. This conservative treatment was successful in three patients (3/10). Septic complication (1 pt) and unsuccessful medical therapy (6 pts) recommended surgical intervention. Decompression procedure (4 pts) and resection (3 pts) were performed. Surgery was successful in all seven patients. We lost no patients and none of them required subsequent surgical treatment.

[Surgical resection of tumors in the distal duodenum]. / Distalis duodenum tumorok rezekciójával szerzett tapasztalataink.

We present six cases of successfully resected primary tumors of the distal part of duodenum (third and fourth segment). Average age of the four male and two female patients was 59 years (47-80). Distal segmental resection were performed in four, pylorus-preserving pancreatoduodenectomy in two cases. Histologically the tumors were five adenocarcinomas, and one gastrointestinal stromal tumor. This tumor causing massive bleeding. In two patients, local lymph nodes were tumor positive, and in one patient synchronous metastasis of the greater omentum was excised during a palliative resection. There was no operative mortality. During a mean follow-up period of 17 months two patients died. Our results support the fact, that radical surgical resection of these tumors, even by segmental resection, provides a more favorable prognosis for duodenal carcinoma than for pancreatic tumors.