Simultaneous aortoiliac kissing Endovascular stenting for management of isolated monolateral common iliac artery aneurysm with no proximal landing zone.

BACKGROUND: Isolated iliac artery aneurysm (IIAA) is an uncommon finding. It, accounts for 0.03% of all patients and 2% of all abdominal aneurysm. Endovascular approach represents the treatment of choice for most patients with IIAA. We reported our experience on iliac aneurysm with no proximal landing zone by simultaneous aortoiliac kissing endovascular (S.A.K.E.) covered stenting. METHODS: This is a retrospective analysis of nine consecutive patients with IIAA with no proximal landing zone, who underwent endovascular kissing covered stenting (Gore®Viabahn®VBX) The median aneurysm diameter was 4.1 cm, with a median 3-mm proximal neck length. In 3/9 aneurysms involving the internal iliac arteries the origin of the internal iliac artery was covered after its embolization and a stent graft extending to the external iliac artery (EIA) was placed. All stents were flared with semi-compliant balloon. RESULTS: Iliac aneurysm exclusion was obtained in all cases (100%), no graft migration or endo-leak were recorded. The median operative time was 28 min; the median fluoroscopy time was 9 min and a median 70 mL of contrast was used. At a median 24-month follow-up, all patients are alive, and no endo-leak or migration, infection, distal embolization, limb loss were observed. Moderate buttock claudication was experienced in 1/9 patients with internal iliac artery embolization. In 6/9 patients a shrinkage of the aneurysmal sac was recorded after 1 year. DISCUSSION: Endovascular management of IIAAs cases has been reported in literature and it was confirmed to be safe and successful. The IAA usually progresses into expansion which eventually leads into rupture. Adequate long proximal and distal landing zones were the most important feature related to better outcomes. Short proximal neck (˂10 mm) represents a real challenge for iliac aneurysm treatment and, nowadays, a classical bifurcated aortoiliac endograft deployment represents the treatment of choice. Endovascular repair of isolated CIA aneurysms with no proximal neck is safe and successful using the SAKE stenting technique with VBX adequately flared and it represents effective and minimally invasive alternative to aortobiliac endograft implantation in the treatment of these aneurysms. To the best of our knowledge, this is the first report which describes this approach in the treatment of IIAA with no adequate proximal landing zone. Our approach overcomes the need to aortic bifurcation graft implantation and reduces procedure time, contrast dose and radiation exposure. It also preserves relevant collaterals vessels thanks to inferior mesenteric artery and lumbar arteries sparing. A proximal aortic bifurcation endograft allows proximal sealing to be regained. Large population study with longer follow-up are needed to establish this approach as a new standard.

Role of mini access during carotid endarterectomy: a prospective observational study.

BACKGROUND: Data from literature confirmed the non-trivial risk associated with carotid revascularization. The purpose of this study is to evaluate carotid endarterectomy (CEA) via a mini-invasive access (3-6 cm longitudinal) incision as a viable alternative to the traditional access via a cutaneous incision (˃6 cm) in terms of nerve sparing and neck pain/disability for patients. METHODS: We performed a prospective, observational, cohort study on 796 consecutive patients who underwent CEAs. A number of 730 patients was included in the final analysis. Patients entered in two different cohorts: CEA with 3-6 cm incision was performed in N.=398 (Group A); CEA with>6 cm incision was performed in N.=398 (Group B). Entire data set is available from 382 in group A and 348 in group B. Adverse events were recorded at 30 days, 3 and 6 months after surgery. The primary purpose of this study was to identify the incidence of cranial nerve injuries and related pain (by Northwick Park Neck Pain Questionnaire [NPq]) in both groups. Differences between groups were exploratory, only, and considered significative for P≤0.05. Secondary objectives were: death, major and minor stroke, transient ischemic attack (TIA), myocardial infarction (MI) and main duration of operation. RESULTS: The cumulative incidence of transient deficit of peripheral nerve in group A was 1.7% at 30 days and 19.4% in group B (RR: 0.10, 95% CI 0.07-0.1, P=0.0001) suggesting a possible benefit from mini-skin incision on nerve injuries reduction. Cranial nerve permanent injuries were identified in 0.17% of mini-incision group and 0.23% of standard group. Exploratory comparison did not demonstrate significative differences between the groups (RR: 0.72, 95% CI 0.19-2.71, P=0.63). The median NPq postoperative score was 40% in GROUP A and 79% in GROUP B (exploratory difference 39%, 95% CI 32.22-45.20%, P=0.0001, χ2: 114.007). At 6 months, NPq was 20% and 42%, respectively; exploratory differences were still present. The need to prolong the mini-incision in GROUP A to preserve the surgical outcome was 1.3%, only. CONCLUSIONS: According to these results the mini skin incision allows a sufficient vessels exposure for dissection, endarterectomy, reconstruction of carotid artery and shunt positioning, minimizing surgical invasiveness, decreasing the incidence of temporary cervical nerve dysfunction and improving the aesthetic result with significative less pain suffered by the patients. Transverse cervical and great auricular nerves sparing decreased postoperative hypo-paresthesia in the neck, improving patient's satisfaction. These data suggest that this procedure can be considered safe. Exploratory analysis suggested that it could possibly be considered a safety alternative to standard carotid endarterectomy. A randomized controlled trial is ongoing for definitive conclusions.

Isolated popliteal artery lesion due to giant cell vasculitis post COVID-19 mRNA vaccine and COVID-19 asymptomatic infection.

OBJECTIVE: Giant cell arteritis (GCA) is a rare granulomatous vasculitis, affecting medium and large vessels, usually in old patients. The incidence of GCA has been higher during current COVID-19 pandemia and COVID-19 is recognized for its immune dysregulation. Lower limbs involvement is uncommon but can be limb threatening, resulting in limb loss. METHOD: A 43-year-old man presented with a sudden pain in his right calf and foot associated with pallor and hypothermia, and there was objective evidence of ischemia. Symptoms began few days after he received the first dose of a COVID-19 mRNA vaccine and COVID-19 asymptomatic infection 20 days after vaccination. He had no history of any signs of claudication pre-COVID or limb trauma and was very fit.Enhanced computed tomography and magnetic resonance imaging (MRI)suggest diagnosis of popliteal artery cystic adventitial disease. We resected the affected popliteal artery with interposition using a right great saphenous vein graft, through a posterior approach. On the fourth postoperative day, he was discharged.Histopathological examination revealed patchy intramural inflammatory infiltrates composed of lymphocytes and rare multinucleated giant cells at the internal lamina and adventitia consistent with a diagnosis of GCA. CONCLUSION AND RESULT: Our case represents the first reported case of isolated popliteal GCA following vaccination with a COVID-19 mRNA vaccine and COVID-19 infection. We propose that the upregulated immune response to the vaccine acted as a trigger for GCA in this patient with predisposing risk factors and recurrent and repetitive microtrauma in popliteal fossa (the patient is a professional runner). Our case suggests the need for further studies about real world incidence of GCA associated vaccination and COVID-19 infection. Currently, data is limited regarding this relationship. We continue to encourage COVID-19 vaccination, even in elderly patients because the benefits of vaccination far outweigh any theoretical risk of immune dysregulation following administration.

Endovascular Treatment with Two Overlapping Micromesh-Covered Stents and Balloon Guide Catheter for Symptomatic Carotid Pseudoaneurysm Ten Years after Eversion Endarterectomy.

Pseudoaneurysm is a rare complication after carotid endarterectomy. Herein, we report a successful endovascular exclusion of a symptomatic carotid pseudoaneurysm occurred ten years after an eversion carotid endarterectomy by means of 2 overlapping micromesh stents (InspireMD C-Guard™) and balloon guide catheter (FlowGate2 Balloon Guide Catheter) used as a proximal protection device.

Anaphylactic Reaction during Implantation of Ovation Abdominal Stent Graft in Patients with Abdominal Aortic Aneurysm.

The Ovation Abdominal Stent Graft System is a trimodular endoprosthesis planned to overcome the limitations of currently available stent grafts, allowing complex iliac and femoral access and providing a proximal seal in challenge infrarenal neck morphology. The proximal sealing is achieved by means of a network of inflatable rings filled with low-viscosity radiopaque polyethylene glycol-based polymer during stent-graft deployment. The leakage of polymer outside the channel to fill the rings into the vascular system may induce an hypersensitivity reaction and anaphylactic shock. We report a case of anaphylactic reaction during Ovation Abdominal Stent Graft System implantation. The endovascular procedure was successfully concluded.

Combined brachial embolectomy and stent graft endovascular exclusion in the treatment of acute arm ischemia due to subclavian artery aneurysms thrombosis or distal embolization.

AIM: Purpose of this study is to report our results after simultaneous transbrachial embolectomy and endovascular aneurysm exclusion with stentgraft in the treatment of upper limb acute ischemia due to subclavian artery aneurysm thrombosis and embolization . METHODS: From January 2010 to December 2015, seven consecutive patients (6 men; mean age 71.5, range 44-85) underwent to emergent revascularization for upper limb ischemia due to thrombosis/embolization of SAA by means of brachial embolectomy and endovascular exclusion. Demographics, clinical, surgical data, complications and survival were recorded. Univariate analysis by chi-square was carried out to evaluate the role of demographics data and risk factors variables on reconstruction patency rate. Primary, primary assisted and secondary patency and limb salvage were calculated using the Kaplan Meyer's life table method. RESULTS: Successful treatment was achieved in all cases. No postoperative death or complications occurred. Primary and assisted primary patency rates at 1 and 3 years were respectively 85.7%, 71.4% and 100%.Secondary patency and limb salvage at 1 and 3 years was 100%. A fatal ischemic stroke occurred in 1 case at 6 months (14.2%). A redo PTA was carried out at 24 months. Univariate analysis showed as demographics data and risk factor variables did not influence the primary, assisted primary, secondary patency rate and limb salvage. CONCLUSION: Endovascular repair is a less invasive alternative to open repair especially in high risk patients. long term results must still be confirmed in further studies. KEY WORDS: Arm ischemia, Endovascular treatment, Subclavian aneurysm.

Conventional carotid endarterectomy versus stenting: comparison of restenosis rates in arteries with identical predisposing factors.

BACKGROUND: The aim of the study was to investigate the possible role of individual predisposition in the pathogenesis of carotid restenosis. METHODS: Over 1700 patients have undergone carotid endarterectomy (CEA) in our institute over the past 15 years. We retrospectively reviewed the charts of those who also had contralateral carotid stenting (CAS) for primary atherosclerotic stenosis and recorded the rates of post-CEA and post-CAS restenosis ≥50%. RESULTS: In the 29 cases analyzed (21 men/8 women), CEA was performed with conventional technique and direct suturing in most cases. Mean ages at the time of CEA and CAS were 69.2±6.6 and 73±6.7 yrs, respectively, and risk profiles at the 2 time points were similar: hypertension (96.5%), dyslipidemia (55.2%), smoking (51.7%), diabetes (31%), coronary artery disease (48.3%), chronic obstructive pulmonary disease (37.9%), and chronic renal failure (13.8%). Antiplatelet therapy protocols were identical for the two procedures. During follow-up (mean: 67.25±51.6 months after CEA, 24.6±16.9 months after CAS), Duplex scans revealed restenosis in 12 patients (9 arteries treated with CEA, 6 managed with CAS). In three patients, restenosis was bilateral. Restenosis-free survival rates at five years were 85% after CEA and 66% after CAS (P=NS). CONCLUSIONS: In this selected group of patients, CEA and CAS were associated with a similar incidence of restenosis. Only 25% of the patients who developed restenosis did so after both procedures. These preliminary findings indicate that individual predisposition does not play a crucial role in the pathogenesis of restenosis. To confirm this conclusion, an analysis of a much larger, multicenter cohort is essential.

Endovascular Treatment of Symptomatic Thrombus of the Descending Thoracic Aorta.

Thoracic aorta mural thrombosis (TAMT) is uncommon pathology with potentially catastrophic complications due to recurrent spontaneous distal embolization. Best treatment, medical or surgical, is still under debate especially in high-risk patients. Endovascular approach by means of thoracic endoprosthesis seems to be a feasible and minimally invasive treatment option. We report a successful treatment of symptomatic TAMT using a thoracic aortic stent graft in a high-risk patient for open repair and contraindication to systemic anticoagulation.

Suprarenal fixation resulting in intestinal malperfusion after endovascular aortic aneurysm repair.

Superior mesenteric artery (SMA) and coeliac axis (CA) occlusion after endovascular abdominal aneurysm aortic repair (EVAR-AAA), using endograft with suprarenal fixation, are uncommon. However, we are reporting a case of visceral malperfusion, which occurred 7 days after successful EVAR with suprarenal fixation for symptomatic AAA. Endograft metal stent barbs caused severe stenosis of SMA and CA. A successful recovery of SMA was carried out by means of a balloon-expandable stent released through bare metal stent barbs. We believe that an unfavourable anatomy of a proximal aortic neck and visceral aorta may have caused a wrong stent strut deployment with the coverage of CA and SMA.

Complete transposition of carotid bifurcation: can it be an additional risk factor of injury to the cranial nerves during carotid endarterectomy?

The internal carotid artery (ICA) usually, lies posterolaterally to the external carotid artery (ECA). Sometimes a complete carotid transposition can occur, with the ECA in a lateral position and the ICA on the medial side can occur. Our study evaluated the significance and impact that this anomaly may have on cranial nerve injuries. From January 2008 to November 2010, 296 patients underwent 360 consecutive primary carotid endarterectomy (CEA) procedures. During carotid isolation, we detected an unexpected lateral position of the ECA in 11 cases (3.6%). χ(2) analysis and the Student's t-test were used to compare the incidence of cranial nerve injuries between the 11 patients with the lateral ECA who underwent CEA (group A) and 11 randomized patients with a normal bifurcation (group B). Statistical significance was inferred at χ(2)>3.84 and P<0.05. A statistical difference in the incidence of superior laryngeal nerve paralysis was detected between groups A and B (18.1%, 2/11 in group A vs. 0%, 0/11 in group B; χ(2)>3.84; P<0.05). No differences in incidence of injury were detected for the other cranial nerves. A very meticulous mobilization of the ECA and ICA is needed to perform CEA, but superior laryngeal nerve injury can occur despite the use of a safe and meticulous surgical technique.