Safety of urgent endarterectomy in acute non-disabling stroke patients with symptomatic carotid artery stenosis: an international multicenter study.

BACKGROUND AND PURPOSE: International recommendations advocate that carotid endarterectomy (CEA) should be performed within 2 weeks from the index event in symptomatic carotid artery stenosis (sCAS) patients. However, there are controversial data regarding the safety of CEA performed during the first 2 days of ictus. The aim of this international, multicenter study was to prospectively evaluate the safety of urgent (0-2 days) in comparison to early (3-14 days) CEA in patients with sCAS. METHODS: Consecutive patients with non-disabling (modified Rankin Scale scores ≤2) acute ischaemic stroke or transient ischaemic attack due to sCAS (≥70%) underwent urgent or early CEA at five tertiary-care stroke centers during a 6-year period. The primary outcome events included stroke, myocardial infarction or death during the 30-day follow-up period. RESULTS: A total of 311 patients with sCAS underwent urgent (n = 63) or early (n = 248) CEA. The two groups did not differ in baseline characteristics with the exception of crescendo transient ischaemic attacks (21% in urgent vs. 7% in early CEA; P = 0.001). The 30-day rates of stroke did not differ (P = 0.333) between patients with urgent (7.9%; 95% confidence interval 3.1%-17.7%) and early (4.4%; 95% confidence interval 2.4%-7.9%) CEA. The mortality and myocardial infarction rates were similar between the two groups. The median length of hospitalization was shorter in urgent CEA [6 days (interquartile range 4-6) vs. 10 days (interquartile range 7-14); P < 0.001]. CONCLUSIONS: Our findings highlight that urgent CEA performed within 2 days from the index event is related to a non-significant increase in the risk of peri-procedural stroke. The safety of urgent CEA requires further evaluation in larger datasets.

Cranial Nerve Injury After Carotid Endarterectomy: Incidence, Risk Factors, and Time Trends.

OBJECTIVE/BACKGROUND: To review the incidence of post-carotid endarterectomy (CEA) cranial nerve injury (CNI), and to evaluate the risk factors associated with increased CNI risk. METHODS: The study was a meta-analysis. Pooled rates with 95% confidence intervals (CIs) were calculated for CNIs after primary CEA. Odds ratios (ORs) were calculated for potential risk factors. A fixed-effects model or a random effects model (Mantel-Haenszel method) was used for non-heterogeneous and heterogeneous data, respectively. Meta-regression analysis was performed to examine the influence of publication year upon CNI rate. RESULTS: Twenty-six articles, published between 1970 and 2015, were included in the meta-analysis, corresponding to 20,860 CEAs. Meta-analysis revealed that the vagus nerve was the most frequently injured cranial nerve (pooled injury rate 3.99%, 95% CI 2.56-5.70), followed by the hypoglossal nerve (3.79%, 95% CI 2.73-4.99). Fewer than one seventh of these injuries are permanent (vagus nerve: 0.57% [95% CI 0.19-1.10]; hypoglossal nerve: 0.15% [95% CI 0.01-0.39]). A statistically significant influence of publication year on the vagus and hypoglossal nerve injury rate was found, with the injury rate having decreased from about 8% to 2% and 1%, respectively, over the last 35 years. Urgent procedures (OR 1.59, 95% CI 1.21-2.10; p = .001), as well as return to the operating room for a neurological event or bleeding (OR 2.21, 95% CI 1.35-3.61; p = .002) were associated with an increased risk of CNI, whereas no statistically significant association was found between CNIs and the type of anaesthesia, the use of a patch, redo operation, and the use of a shunt. CONCLUSION: The vagus nerve appears to be the most frequently injured cranial nerve after CEA, followed by the hypoglossal nerve, with only a small proportion of these injuries being permanent. The CNI rate has significantly decreased over the past 35 years to a point indicating that CNIs should not be considered a major influencing factor in the decision making process between CEA and stenting.

A Review of Open and Endovascular Treatment of Superior Vena Cava Syndrome of Benign Aetiology.

BACKGROUND: The widespread use of central venous catheters, ports, pacemakers, and defibrillators has increased the incidence of benign superior vena cava syndrome (SVCS). This study aimed at reviewing the results of open and endovascular treatment of SVCS. METHOD: Medical literature databases were searched for relevant studies. Studies with more than five adult patients, reporting separate results for the SVC were included. Nine studies reported the results of endovascular treatment of SVCS including 136 patients followed up for a mean of 11-48 months. Causes of SVCS were central venous catheters and pacemakers (80.6%), mediastinal fibrosis (13.7%), and other (5.6%). Percutaneous transluminal angioplasty (PTA) and stenting was performed in 73.6%, PTA only in 17.3%, and thrombolysis, PTA, and stenting in 9%. Four studies reported the results of open repair of SVCS including 87 patients followed up between 30 months and 10.9 years. The causes were mediastinal fibrosis (58.4%), catheters and pacemakers (28.5%), and other (13%). Operations performed included a spiral saphenous interposition graft, other vein graft, PTFE graft, and human allograft. Thirteen patients required re-operations (15%) before discharge mainly for graft thrombosis. RESULTS: In the endovascular group technical success was 95.6%. Thirty day mortality was 0%. Regression of symptoms was reported in 97.3%. Thirty-two patients (26.9%) underwent 58 secondary procedures. In the open group the 30 day mortality was 0%. Symptom regression was reported in 93.5%. Twenty-four patients (28.4%) underwent a total of 33 secondary procedures. CONCLUSIONS: Endovascular is the first line treatment for SVCS caused by intravenous devices, whereas surgery is most often performed for mediastinal fibrosis. Both treatments show good results regarding regression of the symptoms and mid-term primary patency, with a significant incidence of secondary interventions.

Protamine Reduces Bleeding Complications without Increasing the Risk of Stroke after Carotid Endarterectomy: A Meta-analysis.

OBJECTIVES: The aim was to evaluate the safety and efficacy of heparin reversal with protamine after completion of carotid endarterectomy (CEA), summarising the available data from both randomised and non-randomised studies. METHODS: The study was a meta-analysis. Pooled odds ratios (ORs) with 95% confidence intervals (95% CIs) were calculated for the outcomes of stroke and wound haematoma among patients receiving or not receiving protamine after CEA. Meta-regression analysis was performed to examine whether the documented differences were modified by potentially meaningful patient related or procedure related predictors, namely publication year, general anesthesia used, number of patients treated, mean age (years), males, neurological symptoms, use of patch, and use of shunt. RESULTS: Seven studies were included in the meta-analysis reporting on 3,817 patients receiving protamine after CEA and 6,070 patients not receiving protamine for heparin reversal. Only one study was randomised. A statistically significant reduction in wound haematoma requiring re-operation was recorded after heparin reversal with protamine in patients undergoing CEA (OR, 0.42, 95% CI, 0.22-0.80, p = .008). In contrast, no significant difference was observed in stroke rates between groups of patients that received and did not receive protamine (OR, 0.71, 95% CI, 0.49-1.03, p = .07). Meta-regression analysis did not reveal any significant effect mediated by the modifiers examined. CONCLUSION: On the basis of the available data, heparin reversal with protamine seems to reduce the risk of wound haematoma, without increasing the risk of procedural stroke. However, taking into account the limitations of the analysis, further studies are needed to increase the level of evidence provided by the current meta-analysis.

Brachial Artery-Brachial Vein Fistula for Hemodialysis: One- or Two-Stage Procedure-A Review.

Purpose The purpose of the study was to investigate the patency rate of the brachial vein transposition-arteriovenous fistula [BVT-AVF] and to review the available literature regarding the comparison of the one-stage with the two-stage procedure. Methods A multiple electronic health database search was performed, aiming to identify studies on brachial vein superficialization. Case reports and series with five or less patients were excluded from the study. End points of the study were the patency rates at 12, 24, and 36 months of follow-up. The patency of the one- or two-stage BVT-AVF procedure was investigated. Results Overall, 380 BVT-AVFs were analyzed. The primary patency rate at 12 months ranged between 24 and 77%. Rate of early fistula malfunction or failure of maturation of the fistula resulting in loss of functionality ranged from 0 to 53%. Forearm edema, hematomas, wound infection, and early thrombosis were among the most common complications. Limited data were available for the comparison of patency rates between the one- and the two-stage procedure because of the absence of sufficient comparative studies. However, series with one-stage procedure presented a lower patency rate at 12 months compared to series with two stages. Conclusion Patency rates after BVT-AVF, although not excellent, has encouraging results taking into account that patients undergoing these procedures do not have an accessible superficial vein network; failure of maturation and the increased rate of early postoperative complications remain a concern. The BVT-AVF is a valuable option for creating an autologous vascular access in patients lacking adequate superficial veins.

Factors Predisposing to Endograft Limb Occlusion after Endovascular Aortic Repair.

OBJECTIVES: The aim of this study was to investigate risk factors for endograft limb occlusion after endovascular abdominal aneurysm repair (EVAR), using a case control design. METHODS: All patients presenting with endograft limb occlusion after elective EVAR between January 2010 and June 2013, along with age, sex, and type of endograft matched controls were included in the study. The impact of atherosclerotic risk factors, anatomic characteristics of the aneurysm, procedural details, and antiplatelet therapy was investigated. Multivariate logistic regression analysis and conditional logistic regression analysis for 1:3 matched pairs deriving adjusted odds ratios (ORs) with 95% confidence intervals (CIs) in order to detect significant risk factors for endograft limb occlusion among cases and controls were modeled. RESULTS: Of the 439 patients treated by EVAR, 18 patients (4.1%) presented with endograft limb occlusion. These patients were compared to 54 matched controls. Limb occlusion was associated with iliac artery angulation ≥ 60° (OR = 5.76, 95% CI =1.24-26.74; p = .03) or perimeter calcification ≥ 50% (OR =5.87, 95% CI = 1.10-31.32; p = .04). Limb occlusion was also associated with ≥ 15% endograft oversizing in the common iliac artery (OR = 5.54, 95% CI = 1.11-27.60; p = .04). No other risk factors for limb occlusion were recognized. CONCLUSIONS: The presence of significant angulation and calcification of the iliac arteries as well as excessive limb oversizing appear to be independent predictors of endograft limb occlusion after EVAR.

New possibility of AAA treatment with E-vita abdominal device.

The most dramatic shift in the management of abdominal aortic aneurysms (AAAs) occurred in 1991, when the first endovascular AAA repair was reported. Endovascular aneurysm repair has revolutionized the treatment of infrarenal AAAs. In the last few years, the companies have developed renewed models of grafts and have modified delivery systems tending to make them more atraumatic and flexible in order to deal with difficult anatomies and severely atheromatous and tortuous vessels. The aim of the present paper was to analyze the technical characteristics and properties of the new stent-graft system E-vita abdominal XT and to review the current literature. The E-vita abdominal XT stent-graft seems to be safe and reliable; however, long-term results are needed.

Current knowledge on EVAR with the ultra-low profile Ovation Abdominal Stent-graft System.

Endovascular aneurysm repair (EVAR) has revolutionized the treatment of infrarenal abdominal aortic aneurysms (AAAs). The continuous collaboration of surgeons and bioengineers in the improvement of the devices the last two decades, lead to a continuous redesigning and improvement of the various endografts. In the last few years, the majority of companies have developed renewed models of grafts and have modified delivery systems tending to lower profile in order to deal with difficult anatomies. The ultra low profile 14F OD Ovation (Trivascular) Abdominal Stent-graft System with innovative sealing technology achieved through inflatable sealing rings, allows treatment of AAAs with small in diameter access vessels that might be unsuitable for EVAR with other currently available stent-grafts. The aim of the present paper was to analyze the technical characteristics and properties of this endograft and to review the current literature.

The chimney graft technique for preserving renal arteries in stent-graft sealing zones.

Patients with juxtarenal aneurysms require complex surgical open repair, which is associated with increased mortality and morbidity. An alternative procedure that can be used is the "chimney graft" technique. Three cases of abdominal aortic aneurysms were successfully treated in our department with this technique. One type-Ia endoleak occurred which was successfully treated with coiling and biological glue infusion. All of the chimney grafts have remained patent for the period of observation. The "chimney" technique has good results as a bail out procedure in complex EVAR or in well planned difficult cases. Long-term data is necessary to determine the efficacy of this technique.

The European Society for Vascular Surgery guidelines for carotid intervention: an updated independent assessment and literature review.

BACKGROUND AND PURPOSE: Many medical societies now recommend carotid stenting as an alternative to endarterectomy which raises the question of whether the ESVS guidelines are still valid. This review addresses the validity of the ESVS guidelines that refer to carotid stenting based on the evidence available today. METHODS: We conducted a review and meta-analysis based on the original ESVS guidelines paper and articles published over the past 2 years. RESULTS: For symptomatic patients, surgery remains the best option, since stenting is associated with a 61% relative risk increase of periprocedural stroke or death compared to endarterectomy. However, centres of excellence in carotid stenting may achieve comparable results. In asymptomatic patients, there is still no good evidence for any intervention because the stroke risk from an asymptomatic stenosis is very low, especially with the best modern medical treatment. CREST and CAVATAS have verified that mid-term stroke prevention after successful stenting is similar to endarterectomy. EVA-3S, SPACE, ICSS and CREST have provided additional evidence regarding the role of age in choosing therapeutic modality. The role of the cerebral protection devices is challenged by the imaging findings of small randomised trials but supported by large systematic reviews. CONCLUSIONS: The ESVS guidelines that refer to carotid stenting not only remain valid but also have been further strengthened by the latest available clinical data. An update of these guidelines including all of the recent evidence is needed to provide an objective and up-to-date interpretation of the data.

Association between plaque echogenicity and embolic material captured in filter during protected carotid angioplasty and stenting.

OBJECTIVES/DESIGN: The aim of the study was to investigate debris captured in filter embolic protection devices (EPDs) during carotid artery stenting (CAS) and its possible correlation with plaque echogenicity and other risk factors. MATERIALS/METHODS: Between June 2010 and March 2011, 51 consecutive CAS patients (11 females, mean age 71.2 ± 7, 10 symptomatic) who underwent 53 procedures were included in this prospective study. Ultrasonographic Gray-Weale plaque type (I-V, echolucent to echogenic) characterisation was obtained in all cases. The same type of stent and filter EPD was used. Filters were collected and, after macroscopic evaluation, they were examined using the Thin-Prep(®) liquid-based cytology (LBC) technique. RESULTS: Technical success was 100%. Thirty-day stroke and death rates were 1.8% (1/53) and 0%, respectively. Visible debris was detected in eight (15%) filters, whereas LBC revealed the presence of embolic material particles in 30 filters (56.6%). The presence of embolic material into the filter EPD was 2.38-fold increased for every category change from type IV to type I carotid plaques (OR = 2.38, 95%CI = 1.15-4.93). This association remained robust even after adjustment for age, gender and known atherosclerotic disease risk factors (OR = 2.26, 95%CI = 1.02-5.02). In multivariate analysis for risk factors, hypertension was associated with increased presence of embolic material detection in filter EPD (OR = 20.4, 95%CI = 1.28-326.1). The time distance from symptom to CAS was inversely correlated with debris quantity in EPD (Spearman rho -0.716; p = 0.02). CONCLUSIONS: Echolucent plaques, smaller time frame from last symptom and hypertension were associated with increased presence of embolic material.

The critical role of the external carotid artery in cerebral perfusion of patients with total occlusion of the internal carotid artery.

AIM: The ipsilateral external carotid artery (ECA) can potentially provide an important collateral pathway for cerebral blood flow in the presence of occlusion or severe stenosis of the internal carotid artery (ICA), recovering up to 15% of the middle cerebral arterial flow. The aim of the study is to elucidate the role of ECA in cerebral flow of patients with total ICA occlusion. METHODS: Retrospective study of prospectively collected data of 139 patients with total ICA occlusions. The patients were divided to symptomatic and asymptomatic and were categorized in four subgroups according to the stenosis rates: A) ipsilateral ECA<70% and contralateral internal carotid artery stenosis <70%; B) ipsilateral ECA stenosis <70% and contralateral internal carotid artery stenosis ≥70%; C) ipsilateral ECA stenosis ≥70% and contralateral ICA stenosis <70%; D) ipsilateral ECA stenosis ≥70% and contralateral ICA stenosis ≥75%. RESULTS: Fifty eight (41.7%) patients were asymptomatic. The highest rate (48.2%) of asymptomatic patients was in Group A. Among patients with strokes, the highest rate belonged in groups C and D (44.4% and 50% respectively) where ipsilateral ECA stenosis was ≥70% irrespectively of the contralateral ICA patency. Ipsilateral external carotid artery stenosis ≥70% proved to be and independent risk factor for symptom presentation (P=0.013). CONCLUSION: The study reveals the significant role of ECA patency in cerebral flow in patients with ICA occlusion.

Vascular manifestations of Behcet's disease: report of a case and review of the literature.

Adamantiades-Behçet's disease (ABD) is a relapsing vasculitis of unknown aetiology and variable clinical manifestations. The syndrome can be presented in a myriad of ways and can involve nearly every organ. Although vascular involvement is not included among the ABD diagnostic criteria, it is a unique clinical manifestation in adults with a potentially devastating outcome. We report an ABD case, presenting with a thrombotic occlusion of the inferior vena cava. The authors review the recent literature, emphasizing the spectrum of vascular manifestations accompanying Behçet's disease.

Vascular surgery training and its relationship to other surgical specialties.

During the last 50 years vascular surgery has met an enormous evolution, paving the way for the development of modern vascular and endovascular surgery. Although, vascular surgery (VS) has emerged from general (GS) and cardiothoracic surgery (CTS), the need for specialized training has been recognized and gradually practice patterns are shifting towards vascular independence, but yet not in all countries. In these countries VS training is either permitted only after prerequisite GS certification, or as a non accredited surgical specialty, VS might be included in GS or CTS training and certification. Such a policy raises two main issues: the efficiency of vascular training within the GS or CTS curricula and the performance of vascular interventions by general or cardiothoracic surgeons. Meanwhile, the explosion of endovascular procedures has brought new disciplines into play, each one wanting to maintain its stake in the future. Interventional radiologists and a significant number of cardiologists become increasingly involved in the treatment of vascular diseases. The question of which specialist among those qualified should carry out medical treatment, open, and endovascular procedures is still suspended. Under this prism, vascular training issues arise as an important component of the future of vascular surgeons.

Current knowledge on E-vita abdominal endograft.

The field of endovascular abdominal aortic repair has changed remarkably compared to what it was prior to 1993, the year of the first commercial endograft deployment in the United States. Over the years of endovascular aneurysm repair experience, various companies have attempted to construct an ideal stent-graft for exclusion of an abdominal aortic aneurysm (AAA). However, it has become evident that not all abdominal aortic anatomies are amenable to endovascular treatment and that the rationale "one device fits all AAAs" can lead to disastrous results. Different endografts have dissimilar properties and characteristics. Type of graft material, configuration and type of stent structural support, modularity, type of transrenal fixation, are potentially influential factors of endograft behavior. The self-expanding E-vita abdominal stent-graft (JOTEC, Hechingen, Germany) is a relatively new infrarenal, modular stent-graft with suprarenal fixation designed for AAA reconstruction. The present paper analyzes the technical characteristics and properties of this device. We also analyze our experience with the endoprosthesis and review the current literature.

An update of the role of endovascular repair in blunt carotid artery trauma.

Blunt carotid injury (BCAI) is an increasingly recognised entity in trauma patients. Without a prompt diagnosis and a proper treatment, they can result in devastating consequences with cerebral ischaemia rate of 40-80% and mortality rate of 25-60%. Several applied screening protocols and continuously improving diagnostic modalities have been developed to identify patients with BCAI. The appropriate treatment of BCAI still remains controversial and strictly individualised. Besides anti-thrombotic/anticoagulation therapy and surgical intervention, continuously evolving endovascular techniques emerge as an additional treatment option for patients with BCAI. We provide an update on blunt carotid trauma, emphasising the role of endovascular approaches.

Evidence that statins protect renal function during endovascular repair of AAAs.

OBJECTIVES: Several studies have documented a slight but significant deterioration of renal function after endovascular repair of abdominal aortic aneurysm (AAA) (EVAR). The aim of this retrospective study was therefore to investigate whether medication with statins may favourably affect perioperative renal function. MATERIAL AND METHODS: From January 2000 to January 2008, out of a total cohort of 287 elective patients receiving endovascular repair of their AAA or aortoiliac aneurysm, 127 patients were included in the present study, as their medication was reliably retrievable. Patients were divided according to whether their medication included statins (>3 months). Second, they were subdivided according to their supra- (SR) or infrarenal (IR) endograft fixation. Serum creatinine (SCr) and creatinine (CrCl) clearance were determined preoperatively, postoperatively, at 6 and 12 months. Patients with known pre-existing renal disease, with incorrect placement of the stent graft resulting in severe renal artery stenosis, and with occlusion or renal parenchymal infarction were excluded from the study. RESULTS: Patients receiving an infrarenal fixation of their graft had no change in the renal function, regardless whether they were on statins or not. In patients with SR fixation not receiving statins, a deterioration in renal function was observed in the early postoperative period ((SCr) preoperative vs. SCr postoperative: 1.02±0.2 vs. 1.11±0.28, p<0.001 and (Cr.Cl) preoperative vs. Cr.Cl postoperative: 74.1±21.4 vs. 68.0±21.4, p<0.001), whereas patients on statins experienced no change in renal function (SCr preoperative vs. SCr postoperative: 0.99±0.24 vs. 1.02±0.20n.s. and Cr.Cl preop vs. Cr.Clpostop.: 76.4±19.1 vs. 74.28±20.50, n.s.). During follow-up, a constant worsening of renal function at 6 and 12 months was observed, irrespective of the medication with statins. CONCLUSIONS: The present study suggests a slight immediate deterioration of the renal function using (SR) fixation, and this could be prevented by the use of statins. During follow-up, statins did not protect from further renal deterioration. Broader studies are needed to confirm a definitive relation between statin use and renal protection during the endovascular repair of AAA.

Persistent endoleak after endovascular exclusion of an aortocaval fistula, producing renal insufficiency.

This report presents a case of type II endoleak after endovascular exclusion of a primary aortocaval fistula, producing renal vein hypertension and renal insufficiency. A 74-year-old patient presented with acute renal insufficiency, hematuria, lower limb edema, and weight gain. The abdominal CT scan revealed an abdominal aortic aneurysm and an aortocaval fistula. An endograft was deployed but type II endoleak was present and persisted after surgical ligation of the inferior mesenteric artery and subsequent unsuccessful attempt of coil-embolization. The patients renal function continued to be impaired. Surgical ligation of aortocaval communication with preservation of the endograft was performed, resulting in restored renal function.