Systematic review with pooled data analysis reveals the need for a standardized reporting protocol including the visceral vessels during fenestrated endovascular aortic repair (FEVAR).

OBJECTIVES: To collect and analyse the available evidence in the outcomes of patients treated with fenestrated endovascular aortic repair (f-EVAR) technique focusing specifically on visceral vessel outcomes. METHODS: The current meta-analysis was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. All the studies reporting the f-EVAR technique for the management of degenerative pararenal and/or type IV thoracoabdominal aortic aneurysms (TAAA) were considered eligible for inclusion in the study. The main study outcomes (technical success, type I endoleaks, fracture or occlusion of the bridging stents, overall aneurysm-related mortality, and the reintervention rate) were subsequently expressed as proportions and 95% confidence intervals. RESULTS: Fourteen studies with a total of 1804 patients were included in a pooled analysis. The technical success of the procedure was 95.97% (95%CI = 92.35-98.60). Intraoperatively, the pooled proportion of reported type I endoleak was 7.6% (95%CI = 2.52-14.60) while during a median follow-up of 41 months (range 11-96) follow-up period the pooled rate of fracture and occlusion of the bridging stents was 2.79% (95%CI = 0.00-8.52) and 4.46% (95%CI = 1.93-7.77), respectively. The overall aneurysm-related mortality was detected to be 0.63% (95%CI = 0.04-1.63), and the pooled estimate for re-intervention rate was 15.69%. CONCLUSIONS: Fenestrated endovascular repair for p-AAA is an effective and safe treatment. Target vessel complications and endoleaks remain the two most important concerns for fenestrated endovascular procedures, contributing to most of the secondary interventions. The lack of computed tomography angiography follow-up evaluation does not allow us to draw robust conclusions about the complication rates for the superior mesenteric artery during f-EVAR. Due to the potential implications of SMA complications on aneurysm-related mortality, standardized reporting of short- and long-term target visceral vessel outcomes is required.

A systematic review and meta-analysis for the management of Paget-Schroetter syndrome.

OBJECTIVE: There is currently no general agreement on the optimal treatment of Paget-Schroetter syndrome. Most centers have advocated an interventional approach that is based on the results of small institutional series. The purpose of our meta-analysis was to focus on the safety and efficacy of thrombolysis or anticoagulation with decompression therapy. A detailed description of the epidemiologic, etiologic, and clinical characteristics, along with radiologic findings and treatment option details, was also performed. METHODS: The current meta-analysis was conducted using the PRISMA guidelines. Studies reporting on spontaneous thrombosis or thrombosis after strenuous activities of axillary-subclavian vein were considered eligible. Analyses of all retrospective studies were conducted, and pooled proportions with 95% confidence intervals of outcome rates were calculated. RESULTS: Twenty-five studies with 1511 patients were identified. Among these patients, 1177 (77.9%) had thrombolysis, 658 (43.5%) had anticoagulation, and 1293 (85.6%) patients had decompression therapy of the thoracic outlet. Complete thrombus resolution was estimated at 78.11% of the patients after thrombolysis, and the respective pooled proportion for partial resolution of thrombus was 23.72%. Despite thrombolytic therapy, 212 patients underwent additional balloon angioplasty for residual stenosis, although only 36 stents were implanted. After anticoagulation, a total of 40.70% of the patients had complete thrombus resolution, whereas partial resolution was occurred in 29.13% of the patients. During follow-up, a total of 51.75% of the patients with any initial treatment modality had no remaining thrombus, and 84.87% of these patients were free of symptoms. We also estimated that 76.88% of the patients had a Disabilities of the Arm, Shoulder and Hand score of <20, indicating no or mild symptoms after treatment. A subgroup meta-analysis with 20 studies and 1309 patients, showed significantly improved vein patency and symptom resolution in patients who had first rib resection with or without venoplasty, compared with those who had only thrombolysis. CONCLUSIONS: Although no randomized controlled data are available, our analysis strongly suggested higher rates of thrombus and symptoms resolution with thrombolysis, followed by first rib resection. A prospective randomized trial comparing anticoagulants with thrombolysis and decompression of thoracic outlet is required.

Carotid Endarterectomy Using a Flow-Reversal Technique in the Acute Period: A Novel Approach That May Reduce Intraoperative Cerebral Events.

Lesion manipulation during internal carotid artery (ICA) surgical dissection is the most crucial stage of carotid endarterectomy (CEA); a friable part of the carotid plaque or a thrombus may detach from the arterial wall, leading to cerebral embolism. Proximal protection devices used in carotid artery stenting reverse the blood flow to the brain eliminating, at least after their deployment, the chance of cerebral embolism. Based on the working principle of these devices, we propose a new approach to CEA making use of a flow-reversal technique, and we report its successful application in 2 high-risk patients with a soft and friable type 4 ICA plaque: a 62-year-old male patient presenting with crescendo transient ischemic attacks and a 61-year-old male patient presenting with a major stroke. Both were operated in the acute period. Once the reverse flow has been established, the surgeon can freely manipulate the carotid and perform a fast blunt dissection without the risk that the disturbance of the arterial wall may lead to cerebral embolism. A video recording of the procedure has been made and presented with this article. Despite the various limitations, including increased clamping time, transient intolerance to reverse flow, and increased blood loss, this technique may improve clinical outcomes, especially in symptomatic patients with friable plaque. A clinical trial is warranted to further study the results of the flow-reversal CEA.

Surgical treatment of renal neoplasmatic thrombi extending into the inferior vena cava.

Renal cell carcinoma produces neoplasmatic thrombus that usually invades and progressively grows into the endorenal veins. The thrombus may extend into the ipsilateral renal vein or the inferior vena cava in 15-20% and 8-15% of cases, respectively. These tumors are classified into four categories (I, II, III, and IV) according to the level of cephalad extension of thrombus into the inferior vena cava. The purpose of this study was to assess the surgical strategy for cases of renal tumor thrombus invading the vena cava. We retrospectively reviewed the records of 10 patients with renal cell carcinoma, who underwent in our institution radical nephrectomy and resection of vena cava thrombus between January 1997 and December 2004. Four patients were classified as level I, four were level II, and two were level III. In all cases, the thrombus was removed through a small cavotomy without cardiopulmonary bypass and the cavotomy was closed primarily. Pringle's maneuver was performed in the two level III cases. There were no perioperative pulmonary embolisms or deaths, and the mean hospital stay was 8 +/- 1.1 days. The mean survival was 21.8 +/- 8 months, and the vena cava remained patent for this period. Tumor thrombectomy improves the prognosis and the quality of life of these patients, and in most of cases the surgical technique, although challenging, carries a low morbidity and mortality rate.