A Double Nellix and Chimney Covered Stents: Challenging Treatment of Pararenal Aortic Aneurysm.

A 77-year-old male patient presented with a symptomatic, 66-mm pararenal aortic aneurysm. The patient was classified as unsuitable for open surgery due to significant comorbidities. Fenestrated or branched endografts were contraindicated due to the poor iliac access (6 mm diameter). A double Nellix with chimney endovascular aneurysm sealing (ChEVAS) technique was selected to exclude the pararenal aortic aneurysm and to preserve renal arteries and the superior mesenteric artery. Technical preplanning considered the ideal proximal landing zone to be close to the origin of the almost occluded celiac trunk and the distal common iliac arteries as the ideal distal landing zone. The total length of the aorta to cover was estimated as >180 mm, requiring 2 aortic EVAS systems, bilaterally overlapped. Technical success was achieved, and the patient was discharged on postoperative day 8 in good general condition. Successful aneurysm exclusion and target vessel patency without endoleak or stent-graft kinking or migration were confirmed at angio-computed tomography at 6 months.

Effects of passive leg raising on microvascular venous compartment in critically ill patients.

BACKGROUND: Even though fluid loading is thought to improve organ perfusion, the way in which it does so remains unclear. We assessed how the microvascular bed in skeletal muscle reacts to passive leg raising in patients with and without sepsis or septic shock. METHODS: We studied 40 critically ill patients (group A) and 30 healthy controls (group B). The forearm microvascular bed was assessed using near-infrared spectroscopy before and after passive leg raising. We measured stressed and unstressed volumes, inside pressures, blood flow, microvascular compliance and tone. RESULTS: In group A, passive leg raising induced a microvascular bed increase from 4.9 (3.2-6.5) mL/100 mL tissue to 5.7 (3.9-8.1) mL/100 mL tissue (P=0.005), leaving inside pressures unchanged, whereas in group B neither volumes nor pressures changed. Patients without sepsis showed an increase in the stressed volume from 0.22 (0.10-0.28) mL/100 mL tissue to 0.34 (0.23-0.66) mL/100 mL tissue (P=0.039) and a decrease in compliance (P=0.004), whereas, in septic shock, the unstressed volume increased from 4.20 (3.01-5.82) mL/100 mL tissue to 5.32 (4.01-11.50) mL/100 mL tissue (P=0.036). In critically ill patients near-infrared spectroscopy showed no difference in microvascular variables between responders and non-responders to passive leg raising, but responders showed a cardiovascular response shorter than healthy subjects. CONCLUSIONS: Our study provides evidence that macrocirculatory parameters are unreliable to derive measurements of stressed and unstressed volumes. Our results indicate that in septic shock, the enlargement of the unstressed volume associated with passive leg raising induces loss of fluids to the interstitium, thus leaving organ perfusion unchanged or worse.

Hypothermia during Carotid Endarterectomy: A Safety Study.

BACKGROUND: CEA is associated with peri-operative risk of brain ischemia, due both to emboli production caused by manipulation of the plaque and to potentially noxious reduction of cerebral blood flow by carotid clamping. Mild hypothermia (34-35°C) is probably the most effective approach to protect brain from ischemic insult. It is therefore a substantial hypothesis that hypothermia lowers the risk of ischemic brain damage potentially associated with CEA. Purpose of the study is to test whether systemic endovascular cooling to a target of 34.5-35°C, initiated before and maintained during CEA, is feasible and safe. METHODS: The study was carried out in 7 consecutive patients referred to the Vascular Surgery Unit and judged eligible for CEA. Cooling was initiated 60-90 min before CEA, by endovascular approach (Zoll system). The target temperature was maintained during CEA, followed by passive, controlled rewarming (0.4°C/h). The whole procedure was carried out under anesthesia. RESULTS: All the patients enrolled had no adverse events. Two patients exhibited a transient bradycardia (heart rate 30 beats/min). There were no significant differences in the clinical status, laboratory and physiological data measured before and after CEA. CONCLUSIONS: Systemic cooling to 34.5-35.0°C, initiated before and maintained during carotid clamping, is feasible and safe. TRIAL REGISTRATION: ClinicalTrials.gov NCT02629653.