Fenestrated Endovascular Repair for Pararenal or Juxtarenal Abdominal Aortic Aneurysms: a Systematic Review.

BACKGROUND: This review aims to collect all available data on early and late outcomes in patients undergoing fenestrated endovascular aortic aneurysm repair (F-EVAR) for pararenal or juxtarenal abdominal aortic aneurysms (AAAs). METHODS: The Pubmed, Embase, Scopus and Cochrane Library databases were systematically searched to identify eligible studies. Studies reporting at least early mortality after F-EVAR in patients with pararenal or juxtarenal AAA were included. Thirty-day outcomes were defined as early, and outcomes reported after 30 days postoperatively were defined as late. Basic characteristics of all studies and demographics of patients were reported. RESULTS: Overall, 30 studies (17 retrospective and 13 prospective) including 23,385 patients in total were included. Out of 23,385 patients, a total of 2,271 patients were treated with F-EVAR for pararenal/juxtarenal AAA. Overall, 4,216 target vessels were to be treated (data from 24 studies). Pooled early mortality reached 2.55% (ranging from 0% to 6.74%), with a pooled technical success of 96.8% (ranging from 82.8% to 100%). Regarding late outcomes, pooled all-cause mortality reached 17% (ranging from 0% to 50%), 1-year primary patency was 94.6% (ranging from 91.8% to 97.1%) and reintervention rate was 10.4% (ranging from 0% to 57.4%). Mean/median follow-up ranged from 3 to 60 months. CONCLUSIONS: Early outcomes indicate that F-EVAR is a safe and efficient treatment for patients with pararenal/juxtarenal AAAs. Although long-term outcomes are acceptable, late-intervention rate remains high.

Carotid Endarterectomy versus Carotid Stenting or Best Medical Treatment in Asymptomatic Patients with Significant Carotid Stenosis: A meta-analysis.

BACKGROUND: This meta-analysis aimed to evaluate randomized trials (RTs) that compare outcomes among asymptomatic patients with significant carotid stenosis undergoing carotid endarterectomy (CEA) versus carotid stenting (CAS) or best medical treatment (BMT). MATERIAL AND METHODS: The Pubmed, Embase, Scopus and Cochrane Library databases were systematically searched to identify eligible studies. Data were analyzed by using the StatsDirect Statistical software (Version 2.8.0, StatsDirect Ltd). Odds ratios (OR) were used to determine effect size, along with 95% confidence interval (CI). PRISMA guidelines for conducting meta-analyses were utilized. RESULTS: Overall, 10 RTs including 8771 asymptomatic patients were evaluated. Compared to CAS, 30-day all stroke risk was found to be lower after CEA (pooled OR = 0.56; CI 95% [0.312-0.989]; P = 0.046). However, other early and late outcomes were not different between CEA and CAS. Furthermore, 30-day all stroke (pooled OR = 3.43; CI 95% [1.810-6.510]; P = 0.0002), death (pooled OR = 4.75; CI 95% [1.548-14.581]; P = 0.007) and myocardial infarction (MI) (pooled OR = 9.18; CI 95% [1.668-50.524]; P = 0.011) risks were higher after CEA compared to BMT, as expected. Additionally, 30-day all stroke/death and all stroke/death/MI risks were higher after CEA compared to BMT as well. Regarding long-term results, ipsilateral stroke risk was lower after CEA compared to BMT (pooled OR = 0.46; CI 95% [0.361-0.596]; P < 0.0001) although death due to stroke risk was not different (pooled OR = 0.57; CI 95% [0.223-1.457]; P = 0.240). Unfortunately, no study comparing CAS to BMT was found. CONCLUSIONS: CEA is associated with a lower early all stroke risk compared to CAS although other early or late outcomes did not show any difference between the two methods. Additionally, CEA seems to have a benefit over BMT against long-term ipsilateral stroke, although early outcomes are worse after CEA. No studies are available comparing CAS to BMT alone.

Septic superficial thrombophlebitis in Klippel-Trenaunay syndrome.

This is a rare case of a young patient with Klippel-Trenaunay syndrome that presented with extensive septic superficial thrombophlebitis of the lower extremity. Treatment included intravenous antibiotics based on cultures, anticoagulant therapy as well as surgical removal of thrombi.

Conservative treatment of patients with thromboangiitis obliterans or cannabis-associated arteritis presenting with critical lower limb ischaemia.

BACKGROUND: Proper management of patients with thromboangiitis obliterans (TAO) or cannabis-associated arteritis (CAA), presenting with critical lower limb ischaemia (CLI) remains controversial, and data are limited. PATIENTS AND METHODS: Patients with TAO or CAA presenting with CLI between 2011 and 2016 were retrospectively evaluated. Patients requiring primary intervention were excluded. Conservative treatment included: (a) weight-adjusted bemiparin plus six hours/day intravenous iloprost for 28 days, (b) aspirin (100 mg/day) plus cilostazol (100 mg twice/day) after discharge, and (c) strict recommendations/monitoring for smoking cessation. Main outcomes included symptom recession, ankle-brachial index (ABI) improvement, and healing of lesions at the time of discharge as well as amputation, revascularization, and abstinence rate during follow-up. RESULTS: Overall, 23 patients (TAO: 15; CAA: 8) were included within six years, none of the patients reported any other factor than smoking. All patients presented with rest pain and 12 patients with ulcer or necrotic lesions. Mean ABI measurement at presentation was 0.46 ± 0.2, after 28 days of treatment, all patients showed improvement regarding clinical picture and ABI measurement (0.54 ± 0.1; p < 0.05). During follow-up, only three patients underwent bypass surgery and two patients underwent major amputation, although the smoking abstinence rate was very low (13 %). CONCLUSIONS: Intravenous iloprost plus bemiparin for 28 days together with per os aspirin plus cilostazol seem to produce promising results in patients with TAO/CAA, treated for CLI, even with a low smoking abstinence rate. However, larger series are needed to further evaluate inter-group differences and potential prognostic factors.

Thrombolysis in peripheral artery disease.

Peripheral artery disease (PAD) has been associated with severe morbidity and mortality worldwide, affecting the quality of life for millions of patients. Acute thrombosis has been identified as a major complication of PAD, with proper management including both open as well as endovascular techniques. Thrombolysis has emerged as a reasonable option in the last decades to treat such patients although data produced by randomized trials have been limited. This review aims to present major aspects of thrombolysis in PAD regarding its indications and contraindications, technique tips as well as to review literature data in order to produce useful conclusions for everyday clinical practice.

Bilateral Type IIIa Endoleak and Disconnection of Both Limbs after Evar with an Endurant II Endograft.

A 75-year-old patient with severe comorbidities was treated with an Endurant® (Medtronic, USA) II endograft due to a ruptured abdominal aortic aneurysm (AAA). After four years of unremarkable follow-up, bilateral limb separation was detected. The patient underwent endovascular bridging without any complication. Although rarely detected in newer grafts, late bilateral type IIIa endoleaks can present and should be promptly repaired. Complex or ruptured AAAs treated with off-label use of endografts should be under closer surveillance using imaging tools for potential endoleaks or aneurysm sac growth.

Iatrogenic and non-iatrogenic arterial injuries in an urban level I trauma center in Greece.

BACKGROUND: Aim of this study is to present the experience of an urban trauma center concerning the management of vascular trauma. METHODS: All data on major arterial injuries of the extremities treated during a 6-year period (August 2008 - August 2014) were retrospectively collected and analyzed. All cases were classified into iatrogenic and non-iatrogenic injuries, and comparisons were made between the two groups. Arterial injuries of the thorax and abdomen as well as venous injuries were not included. RESULTS: Overall, 67 major arterial injuries were managed (22% iatrogenic). Iatrogenic and non-iatrogenic cases showed differences regarding sex, age and injury of adjacent structures. Almost 8% of patients underwent primary amputation, with major nerve, long bone or extensive soft tissue injury being the main risk factors. Most iatrogenic cases underwent endovascular treatment, although open repair with venous grafting was the primary choice for non-iatrogenic injuries. Primary patency was 100% for all open repairs, although secondary patency was 97% after one month of intervention. Eight cases needed secondary amputation, with extensive soft tissue loss being the major risk factor for secondary amputation. CONCLUSIONS: Iatrogenic and non-iatrogenic arterial injuries show different characteristics concerning epidemiology and management. Injury of main adjacent structures remains a major risk factor for primary as well as secondary amputation. Endovascular treatment when indicated remains a therapeutic choice with optimal results.

Bioabsorbable stenting in peripheral artery disease.

Arterial stenting has been broadly utilized for the management of peripheral arterial occlusive disease. The evolution of stent materials has led to the introduction of newer bioabsorbable scaffolds that have been extensively evaluated in the treatment of coronary artery disease. However, the utilization of bioabsorbable stents in the lower extremities remains challenging and has not been evaluated in the same degree. There are not many trials focusing on major outcomes of treatment with bioabsorbable stents or comparing them with other therapeutic choices such as surgery or angioplasty only. The aim of this review is to report current status on bioabsorbable stenting in peripheral artery disease treatment as well as to present the results of all major relevant trials. Moreover, future expectations and challenges with this type of stents are discussed as well.

Hybrid treatment of lower limb critical ischemia in a patient with systemic lupus erythematosus.

Systemic lupus erythematosus (SLE) is a chronic inflammatory multisystemic disease, which affects primarily small-sized vessels, arterioles, venules, and capillaries in the cardiovascular system. Less often, medium-sized vessels are affected, and large-sized vessels are affected rarely. We report an unusual case of a 52-year-old female patient with SLE under treatment and multileveled arterial obstructive disease of the lower limb, who presented with critical limb ischemia. The patient was treated using a hybrid endovascular and open revascularization procedure, on the basis of the clinical picture of the patient, the angiographic findings, and the experience of our department. Our aim is not only to highlight the rarity of the clinical picture but also to make useful conclusions regarding the proper management for such unusual cases. Given the fact that there are no guidelines, we present the treatment strategy selected for our patient and discuss our results.

Multidisciplinary Management of Carotid Body Tumors in a Tertiary Urban Institution.

Objective. Aim of this study is to present the experience of our institution in carotid body tumors (CBTs) treatment. Methods. All cases treated in a Vascular Surgery Department within 2.5 years (03/2013-09/2015) were retrospectively evaluated. Demographics, diagnostic, and treatment strategy were recorded. All patients with known CBT underwent ultrasound and magnetic resonance imaging preoperatively. All cases were classified according to the Shamblin type and evaluated by a radiologist, otolaryngologist, and anesthesiologist before and after surgery. Major outcomes included mortality, stroke, cranial nerve injury, and recurrence. Results. Overall, nine patients (mean age: 59.5 ± 16.3 years) with a total of ten CBTs were treated. There was no gender prevalence and most of the cases (55%) were asymptomatic. There were no functional or familial cases. There was only one bilateral case treated in a staged manner. No preoperative embolization of CBTs was performed. Mortality and stroke rates were null. No severe complication was observed in the early and late setting. No malignancy was recorded. Mean follow-up was 15.6 ± 7.8 months. Conclusions. Multidisciplinary management of patients with CBTs is imperative for optimal results, especially in type III tumors, bilateral or functional cases. After careful treatment planning and intraoperative manipulations, complications could be avoided even without preoperative embolization.

Primary aortoenteric fistula due to septic aortitis.

Primary aortoenteric fistula is most commonly caused from erosion of the bowel wall by an abdominal aortic aneurysm. Septic aortitis with pseudoaneurysm formation and finally erosion into the duodenum represents a rare cause that has been described in very few patients in the literature. We present a rare clinical case of Salmonella aortitis and associated infrarenal aortic pseudoaneurysm that evolved into an aortoduodenal fistula. A 51-year-old man was admitted in our hospital with symptoms and signs of sepsis caused by Salmonella bacteremia. Imaging studies revealed an infrarenal aortic pseudoaneurysm. The patient presented hemodynamic instability, and during emergency laparotomy a fistula was found between the third portion of the duodenum and a false aneurysm arising from a nonaneurysmal grossly infected aorta. The affected aortic segment was excised and the intestinal defect was repaired. The aortic stumps were sutured and an axillobifemoral bypass was performed. The patient had an uncomplicated postoperative course.