Mid-term Results of Endovascular Reconstruction of Aortic Bifurcation Using COVERA Stent Graft.

INTRODUCTION: This article aims to evaluate the short-term and mid-term performance of a self-expanding covered stent (COVERA Plus, Bard Tempe, Arizona) during the treatment of Trans-Atlantic Inter-Society Consensus (TASC) C/D aortoiliac obstructive lesions involving the aortic bifurcation. METHODS: A single-center retrospective review of all patients who underwent endovascular reconstruction of the aortoiliac bifurcation for obstructive disease, with the use of Covera, from January 2018 to March 2023. All patients received a postoperative CTA (computed tomography angiography) scan within 1 month from the intervention. Precision of deployment, stent conformation, and stent symmetry were evaluated at the arterial phase of the CTA. Early outcomes were technical success and freedom from open aortic reintervention and/or mortality. Late outcomes were primary and assisted primary patency rates and freedom from reintervention. RESULTS: During the study period, 35 patients underwent primary endovascular treatment of obstructive lesions involving the aortic bifurcation with parallel COVERA stents. Aortoiliac lesions were classified as TASC-IIC in 23 (65.7%) patients and TASC D in 12 (34.2%). Median follow-up was 49 months (interquartile [IQR]: 18-60). Overall survival was 97.1% (95% confidence interval [CI]=91-100) at 60 months. During follow-up, there were one early stent stenosis, treated with an angioplasty and stent relining with an estimated primary patency at 60 months of 97.1% (95% CI=94-100) and a primary-assisted patency of 100%. Estimated freedom from all types of reinterventions at 60 months was 94.3% (95% CI=89-99.3). CONCLUSIONS: The new self-expanding covered Bard COVERA Plus stent used for endovascular treatment of TASC C/D aorto iliac disease proved to be safe and feasible with high technical procedural success rates. Comparison with other types of stents is necessary to further assess the role of the COVERA Plus stent in aortic bifurcation repair. CLINICAL IMPACT: This study investigates the safety and feasibility of the new self-expanding covered Bard Covera Plus stent used for endovascular treatment of TASC C/D aorto iliac disease. The retrospective analysis of 35 patients highlights high technical success and primary patency rate at 60 months. The geometric analysis also helped to underline how this stent can be used precisely in particular conditions. These findings suggest the need for further research to compare COVERA with other types of stents in aortic bifurcation repair.

Early and midterm outcomes of hybrid first line treatment in patients with chronic limb threatening ischemia.

OBJECTIVE: The aim of the study was to evaluate the outcome of first line hybrid treatment in patients with chronic limb threatening ischemia (CLTI) and to evaluate possible predictors of primary patency (PP) loss and limb clinical improvement (LCI). METHODS: This was a retrospective non-randomized study. All patients underwent one-stage hybrid common femoral artery (CFA) endarterectomy combined with an inflow and/or outflow endovascular revascularization procedure. Demographic, clinical, and lesion characteristics for each patient were reported. Primary patency analysis was performed using Kaplan-Meier life tables, and univariate and multivariate analysis was used to assess possible predictors of PP loss and clinical improvement. RESULTS: Complete data were obtained from 132 patients. Patients were divided into two groups according to their Rutherford's category (RC), group 1 (Rutherford 4) and group 2 (Rutherford 5 and 6). Technical success was 98%. The overall surgical peri-operative complication rate was 8%. At a mean follow-up of 32 ± 23 months, the rate of major adverse limb events (MALE) was 30%; only the rate of major amputation between two groups was significant statistically different (p = .006). Group 1 had significantly lower amputation rate at 36 months (p = .01). The presence of high iliac peripheral artery calcium scoring system (PACCS) grade (HR 9.43, 95% CI 2.40-36.9, p = .001), the poor run-off of leg vessels (HR 0.15, 95% CI 0.02-0.92, p = .04), and undergoing CFA endarterectomy combined with outflow endovascular revascularization procedure (HR 4.25, 95% CI 1.07-16.89, p = .04) were independent predictors of PP loss, while severe iliac artery stenosis (OR 0.09, 95% CI 0.02-0.32, p = <.001) and the presence of pre-operative patent leg vessels (OR 8.03, 95% CI 2015-29.95, p = .002) were the significant independent predictors of LCI. CONCLUSION: The use of hybrid first line approach in patients with CLTI is a safe and feasible technique. From the analysis of the current study, it is clear that any effort should be made to achieve as many patency leg vessels as possible in order to obtain better and longer lasting clinical outcomes.

Impact of Cone Beam Computed Tomography in Advanced Endovascular Aortic Aneurysm Repair Using Last Generation 3D C-arm.

BACKGROUND: To report the early outcomes of cone beam computed tomography (CBCT) using last generation 3D C-arm in patients undergone advanced endovascular aortic aneurysm repair (AdEVAR) and to identify risk factors that may predict any un-planned procedures. METHODS: Patients undergone AdEVAR between December 2017 and December 2018 were enrolled. Final CBCT was performed in all patients after digital subtraction angiography. Primary end points were the incidence of any positive findings and the following unplanned procedures intended as any endovascular manoeuvre performed to fix such technical defect. The secondary endpoints were comparison of outcomes between patients with positive findings undergone unplanned procedure (Group A) versus patients without findings (Group B). RESULTS: 132 patients underwent endovascular treatment for aortic aneurysm. Of these, 22 (33%) fenestrated-branched endovascular aneurysm repairs (F-BEVAR), 21 (29%) EVAR with iliac branch devices, 19 (26%) abdominal and 10 (14%) thoracic EVAR were included in the study. Unplanned procedures after CBCT were necessary in 22 patients (31%). Patients in both groups were similar excepted for BMI >25 kg/m2 (55% vs. 26%), hostile iliac anatomy (64% vs. 32%) and previous aortic treatment (73% vs. 32%) (P < 0.05). The odds ratios for unplanned procedure in case of previous aortic treatment was 6.76 (95% CI, 1.97-23.16; P = 0.002). CONCLUSION: The use of CBCT, especially in challenging scenarios, can reveal technical defects and may potentially limit the need for late reintervention. Patients undergone previous aortic surgery should be carefully evaluated and routine CBCT should be performed.

Carotid Endarterectomy with Modified Eversion Technique: Results of a Single Center.

BACKGROUND: Carotid endarterectomy (CEA) has a wide range of approaches based on personal expertise and preference. We evaluated our outcome with CEA with modified eversion technique (meCEA) under local anesthesia and whether the surgeon's experience could influence it. METHODS: at our Institution, 837 patients underwent CEA across 8 years. Although the surgical technique was standardized, 2 groups were considered further: meCEA performed by a single Senior Operator (Group A) and meCEA performed by 4 young Consultants (Group B). RESULTS: A selective shunting policy was needed in 5.1%, together with general anesthesia. Overall operative time was 63.9 ± 15.1 minutes (61.4 ± 12.5 and 66 ± 16.9 minutes in Group A and Group B respectively; P < 0.001) and cross-clamp time 19.3 ± 2.9 minutes (19.0 ± 3.2 vs. 19.5 ± 2.8, P = 0.009). At 30 days, 0.7% TIA and 0.8% strokes were recorded. No differences (p = N.S.) between the 2 study groups in terms of postoperative neurological complications, with postoperative ipsilateral strokes always < 1%. At a median imaging follow-up of 22.5 months, the overall percentage of restenosis was 3.7%, with no difference between the 2 groups (P = 0.954). Twenty-two patients (2.6%) underwent reintervention for significant restenosis, and none of them had an ipsilateral stroke or TIA. Freedom from reintervention for restenosis at 24 months was 97.9% in Group A and 95.9% in Group B, with no between-group difference (P = 0.14). At the median survival follow-up of 37 months, the overall survival rate at 24 months was 97.9%in Group A, and 97.9% in Group B, with no between-group difference (P = 0.070). CONCLUSIONS: In our experience, CEA with a modified technique is safe and achieves comparable outcomes to those of other established techniques. The reported short cross-clamp time, also in less experienced hands, is an additional strength.

Comparison of Endovascular Versus Bypass Surgery in Femoropopliteal TASC II D Lesions: A Single-Center Study.

BACKGROUND: In patients with severe occlusive disease (Trans-Atlantic Inter-Society Consensus II D [TASC II D]) of the femoropopliteal segment, the advantages of endovascular versus bypass revascularization still remain debated. Most reports available in literature comparing percutaneous transluminal angioplasty (PTA) ± bare metal stent (BMS) versus synthetic bypass analyze patients with heterogeneous anatomical lesions creating possible bias when results of different treatments are matched. In this study, we compared early and midterm outcomes of PTA ± BMS versus heparin-bonded expanded polytetrafluoroethylene graft (Propaten-Gore) + Linton patch in patient affected by symptomatic femoropopliteal TASC II-D lesions. METHODS: Eighty limbs with symptomatic severe occlusive disease (TASC II D) of the femoropopliteal segment observed from January 2013 to January 2017 were included in this retrospective study. Indication to treatment was severe claudication in 17 limbs (21.2%) and critical limb ischemia (CLI) in 63 (78.8%). 36.2% of limbs presented at least 2 distal patent vessels, and 63.8% had only 1 patent vessel. Of these limbs, 40 were treated by means of PTA ± BMS (group A), and 40 were treated by means of femoropopliteal bypass with Propaten-Gore graft + Linton patch (group B). Patients were followed with a clinical assessment and duplex at 1, 6, and 12 months after procedure and then annually. A closer follow-up was performed in case of any complication. Patency, reintervention rate, and limb salvage were compared in the 2 groups. RESULTS: The mean length of arterial occlusion was 22.1 cm (range, 8-37) in group A versus 25.2 cm (range, 9-41) in group B, P = ns. A slight difference in mean procedural time was observed (83.5 min of group A versus 114 min of group B, minutes, P = 0.02). Mean follow-up was 26.7 months (range, 3-46). Primary patency at 6, 12, and 24 months of group A versus group B was 76.9% vs. 97.5% (P = 0.007), 65.7% vs. 89.1% (P = 0.05), and 52.6% vs. 78.1% (P = 0.005), respectively. Assisted primary patency was 76.9% vs. 97.5% (P = 0.007), 68.5% vs. 91.8% (P = 0.02), and 57.8% vs. 87.5% (P = 0.001), respectively. Secondary patency was 94.8% vs. 97.5% (P = ns), 85.7% vs. 97.2% (P = ns), 73.6% vs. 93.7% (P = 0.004), respectively. Rate of reintervention at 24 months was 45% in group A vs. 20% in group B (P = 0.03). Limb salvage rate at 24 months was 90% for group A vs. 92.5% for group B (P = ns). Univariate analysis showed CLI and poor runoff to be independent risk factors for significant restenosis/occlusion of target artery and reintervention. CONCLUSIONS: In patients with severe femoropopliteal occlusive disease (TASC II D), the surgical revascularization by means of Propaten-Gore bypass + Linton patch can be considered safe and effective. Early and midterm results of this approach seem to be superior to PTA ± BMS in terms of restenosis/occlusion and reintervention rates. Larger cohort and longer term results are mandatory to better define this advantage.

Red blood cell distribution width (RDW) is an independent predictor of post-implantation syndrome in patients undergoing endovascular aortic repair for abdominal aortic aneurysm.

BACKGROUND: This observational, retrospective study aims establishing the role of red blood cell distribution width (RDW) for identifying abdominal aortic aneurism (AAA) patients at risk of developing post-implantation syndrome (PiS) after endovascular aneurysm repair (EVAR). METHODS: The study population consisted of all patients undergoing EVAR for AAA at the University Hospital of Verona (Italy), between June 1, 2016 and May 31, 2018. Blood samples for measuring hemoglobin, mean corpuscular volume (MCV) and RDW were collected at hospital admission and the day after EVAR. The primary endpoint was PiS development. Delta variations were calculated as the ratio between values measured after and before EVAR. RESULTS: The final study population consisted of 124 patients (10 women and 114 men; median age, 75 years), 55 of whom developed PiS. In patients with or without PiS hemoglobin significantly decreased after EVAR, whilst RDW significantly increased in patients with PiS and decreased in those without. Age, sex, hypertension, diabetes and renal failure were similar in patients who developed PiS or not, whilst a positive history of coronary artery disease was more frequent in PiS patients. Although hemoglobin and MCV changes after EVAR did not differ in patients with or without PiS, delta RDW was higher in those with PiS. The rate of patients with delta RDW >1 was significantly higher in patients with PiS that in those without (61.8% vs. 34.8%; P=0.002). In multivariate analysis, delta RDW remained independently associated with PiS (ß coefficient, 2.023; P=0.001). A delta RDW >1 after EVAR was associated with ~3-fold enhanced risk of PiS (odds ratio, 3.04; P=0.003) and exhibited a good prognostic performance (area under the curve, 0.69; P<0.001). CONCLUSIONS: Calculation of delta RDW after EVAR seems an efficient prognostic tool for stratifying the risk of developing PiS, especially in the early postoperative period.

A Strange "Collection" after Surgery for an Aneurysm of the Popliteal Artery.

The popliteal fossa is the site of several diseases that may be similar in the clinical setting but very different in etiology, treatment, and prognosis. The contemporary presentation of more than one of these conditions is a rare though potentially fatal combination that may lead to a delay in the diagnosis and therapeutic approach. In this report, we describe the case of a patient who presented at our Vascular Department for persistent pain and severe swelling of the right popliteal fossa 8 months after the surgical treatment of a symptomatic popliteal aneurysm by mean of a Dacron prosthetic graft. With the suspect of the graft infection, as defined by angio-computer tomography and fluorodeoxyglucose positron emission tomography, the patient underwent graft removal and revascularization with a biologic conduit. Subsequent surgical revisions for unjustified recurrent hematic collections were necessary without any significative clinical improvement. The histologic analysis of the removed tissue was consistent with a high-grade sarcoma, and the patient underwent above-the-knee amputation of the right limb.

Should current criteria for detecting and repairing arteriovenous fistula stenosis be reconsidered? Interim analysis of a randomized controlled trial.

BACKGROUND: The vascular access guidelines recommend that arteriovenous fistulas (AVFs) with access dysfunction and an access blood flow (Qa) <300-500 mL/min be referred for stenosis imaging and treatment. Significant (>50%) stenosis, however, may be detected in a well-functioning AVF with a Qa > 500 mL/min, too, but whether it is worth correcting or not remains to be seen. METHODS: In October 2006, we began an open randomized controlled trial enrolling patients with an AVF with subclinical stenosis and Qa > 500 mL/min, to see how elective stenosis repair [treatment group (TX)] influenced access failure (thrombosis or impending thrombosis requiring access revision), or loss and the related cost compared with stenosis correction according to the guidelines, i.e. after the onset of access dysfunction or a Qa < 400 mL/min [control group (C)]. An interim analysis was performed in July 2012, by which time the trial had enrolled 58 patients (30 C and 28 TX). RESULTS: TX led to a relative risk of 0.47 [95% confidence interval (CI): 0.17-1.15] for access failure (P = 0.090), 0.37 [95% CI: 0.12-0.97] for thrombosis (P = 0.033) and 0.36 [95% CI: 0.09-0.99] for access loss (P = 0.041). In the setting of our study (in which all surgery was performed as in patient procedure) no significant differences in costs emerged between the two strategies. The mean incremental cost-effectiveness ratio for TX was €282 or €321 to avoid one episode of thrombosis or access loss, respectively. CONCLUSIONS: Our interim analysis showed that elective repair of subclinical stenosis in AVFs with Qa > 500 mL/min cost-effectively reduces the risk of thrombosis and access loss in comparison with the approach of the Kidney Disease Outcomes Quality Initiative (KDOQI) guidelines, raising the question of whether the currently recommended criteria for assessing and treating stenosis should be reconsidered.

Lower Limb Ischemia: Aortoiliac Thrombosis Related to Antiphospholipid Syndrome (APS)-Case Report and Review of the Literature.

Antiphospholipid syndrome (APS) is recognized as one of the main determinants of hypercoagulable conditions. The literature reports the incidence of this syndrome in a third of patients who underwent surgery for peripheral revascularization. Antiphospholipid antibodies are divided into two categories in relation to specific diagnostic tests. The first group is called lupus anticoagulant and consists of immunoglobulins that inhibit the phospholipid dependent coagulation tests in vitro. The second group is defined by their ability to conduct the phospholipid in an ELISA test. The occurrence of thrombotic events in patients with systemic erythematosus lupus (SEL) and anticoagulant antibodies was described for the first time in 1963 by Bowie. The discovery of anti-cardiolipin antibodies in antiphospholipid syndrome is due to Harris et al. who described the syndrome. Primitive APS was consequently defined in the absence of further underlying illnesses. In this disease, arterial thrombosis occurs mainly in the brain. Peripheral arteries are affected less frequently. Thrombosis of the great vessels is reported as anecdotal.