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.

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 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.

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.

Urgent CAS for patients in high neurologic risk.

Patients with residual carotid stenosis discovered following an acute ischemic insult represent a new subset of patients eligible for early carotid intervention that may decrease the risk of recurrent stroke by new emboli and improve cerebral blood flow. Short-term clinical outcomes of patients undergoing urgent CAS appear favorable, indicating that endovascular management may be a reasonable treatment option, particularly when combined with endovascular interventions for intracranial lesions. Data on indication and complication profiles are still limited. This review focuses on current knowledge, advantages and pitfalls of urgent and/or early (up to 2 weeks) carotid stenting in those presenting with an acute neurologic event or recently symptomatic carotid stenosis.

Lower extremity bypass procedures in diabetic patients with end-stage renal disease: is it worthwhile?

BACKGROUND/AIMS: Limb-threatening ischemia in patients with end-stage renal disease (ESRD) represents a challenging therapeutic problem. Furthermore, diabetes mellitus is frequently associated with ischemic gangrene, persistent infection and impaired wound healing. The present study was undertaken to examine graft patency, limb salvage and survival in patients with ESRD and diabetes following bypass grafting to treat lower limb critical ischemia. METHODS: A retrospective analysis of 56 arterial reconstructions performed in 39 patients with diabetes mellitus and ESRD during a period of 8 years. The indications for bypass grafting were: ischemic rest pain (n = 13), non-healing ulcer (n = 18) or foot gangrene (n = 25). Risk factors in association with surgical morbidity and mortality, limb loss and graft patency were evaluated. RESULTS: Thirty-four patients were on hemodialysis and 5 on peritoneal dialysis. Forty-nine infrainguinal reconstructions were performed; the site of distal anastomosis was the below knee popliteal artery (n = 22), the anterior tibial artery (n = 12), the posterior tibial artery (n = 8), and the peroneal artery (n = 7). Seven axillofemoral reconstructions were also performed; the site of distal anastomosis was the common femoral artery (n = 5) and the above knee popliteal artery (n = 2). The 30-day operative mortality rate was 18% (7 patients). The mean follow-up was 11.5 (range 1-93) months. Patient survival rate at 1 and 2 years was 63 and 45%, respectively. Primary patency rate was 64% at 1 year and 58% at 2 years. The limb salvage rate was 65% in the first year. CONCLUSION: Limb salvage rate in patients with ESRD and diabetes justifies an aggressive policy of revascularization, despite decreased survival of this population.