Carotid artery stenting: Influence of experience and cerebrovascular risk factors on outcome.

AIM: To evaluate technical success, complications and the influence of the learning curve on outcome in carotid artery stenting (CAS) performed in patients not suitable for surgery. PATIENTS AND METHODS: One hundred and nine procedures of protected carotid stenting in 103 high risk patients were performed. All patients presented at least one factor that potentially increased the surgical risk of carotid endoarterectomy (CEA), according to SAPPHIRE criteria. Neurologic complications were quantified by the National Institutes of Health Stroke Scale (NIHSS) and were evaluated by median Rankin Scale (mRS). To evaluate the influence of experience of the operator to perform CAS, we retrospectively analyzed periprocedural and neurological complications of the first 50 procedures compared with that of the following 59 interventions. RESULTS: Technical success rate was 98%. Neurological periprocedural complications were revealed in 4.5% of patients. In-hospital and 30-days neurological complications rate was 7.6 and 2.6% respectively. Periprocedural neurological complications rate was lower in the last procedures performed, according to a higher confidence of the operators. CONCLUSIONS: CAS may be performed as an alternative of CEA for the treatment of severe carotid obstructive disease in patients not suitable for surgery. The learning curve positively influence complications rate.

Delayed graft dislocation after thoracic aortic endovascular repair.

BACKGROUND: Endograft dislocation in thoracic aorta has not been widely studied. OBJECTIVES: The purpose of this study is to analyze the incidence and predisposing factor in a single centre experience after 117 procedures. METHOD: Between November 2000 and December 2011, all consecutive patients undergoing endovascular repair for descending thoracic or thoraco-abdominal aortic disease were identified. Follow-up imaging protocol included triple-phase CT-angiography at 1, 4, and 12 months, and annually thereafter. Migration was defined as proximal/ distal movements >10 mm relative to anatomical landmarks or any movement leading to symptoms or reintervention. RESULT: We identified 117 patients. Mean follow-up was 32 months (range, 1-144). Overall, five (4.3%) patients with thoracic EG dislocation were identified. Dislocation was classified as collapse/infolding in 3 cases and migration in 2. Mean delay of the dislocation was 12.7 months. Only one patient developed symptoms and required an additional endograft. In the group of dislocated endografts, mean age (53 ± 20 vs. 68 ± 15, P = .032) and the diameter of the aortic lesion were lower (4.1 cm ± 1.6 vs. 5.6 cm ± 1.8, P = .069), and the proximal landing zone at "zones 2 and 3" were more frequently used (5 vs. 65, P = 0.81). All but one patient with collapse/infolding are still alive and doing well at a mean follow-up of 80 months. CONCLUSION: Dislocation is an infrequent complication, but not so rare. Young age, small aortic diameter , and proximal sealing at the distal arch were the most important data associated with this complication.

Endovascular treatment for para-anastomotic abdominal aortic and iliac aneurysms following aortic surgery.

AIM: The aim of this study was to report our experience with endovascular repair of anastomotic aneurysms occurring after graft replacement for abdominal aortic aneurysms or aorto-iliac obstructive disease. METHODS: Between January 2000 and April 2006, 19 consecutive male patients (median age 73 years) underwent endovascular repair for 22 anastomotic aneurysms [proximal aortic (n=15), iliac (n=4), concomitant aortic and iliac (n=3)], occurring 3 months to 18 years (mean 8.6 years) after open surgery. Three patients (15.7%) underwent emergency treatment for rupture. No patient had symptoms or positive blood tests for infection of the original graft. Twelve patients were treated with a bifurcated stent-graft, 4 patients with a proximal stent-graft cuff, 2 patients with a tube iliac stent-graft, and 1 patient with a mono-iliac stent-graft. RESULTS: Stent-grafts were successfully deployed in all patients. Procedure-related complications or death were not observed; open conversion was never required. Median hospitalisation was 9 days (range 3-45). During a median follow-up of 16 Euro-months (range, 2-44) all anastomotic aneurysms maintained excluded: 4 patients (21%) died. We observed 1 major complication (5.2%): an iliac branch occlusion occurred 1 month after the procedure, successfully treated with catheter-directed thrombolysis. Overall, survival rates at 6, 12, 18 and 36-months were 92.8%, 84.4%, 72.3%, and 57.8% respectively. CONCLUSION: Our experience confirms that endovascular stent-grafts can be used successfully to exclude anastomotic aortic aneurysms after open surgery. Endovascular repair seems to be effective at mid-term follow-up.

Mid-term results of endovascular reconstruction for aorto-iliac obstructive disease.

AIM: Aorto-iliac obstructive disease has been traditionally treated with endarterectomy and/or a surgical bypass graft. Kissing-stents technique has been proposed to reconstruct the aorto-iliac bifurcation for complex aorto-iliac lesions. METHODS: We report 43 patients with complex aorto-iliac occlusions managed with endovascular repair. Between March 1999 and October 2005, a total of 43 patients with a mean age of 66+/-10 years underwent endovascular treatment for aorto-iliac obstructive disease. Lesions were classified C (n=34) and D (n=9), accordingly to the Trans-Atlantic Inter-Society Consensus (TASC) classification. All endovascular interventions were performed in the theatre under regional anesthesia. Predilation with kissing-balloons angioplasty was usually performed; the bifurcation was then eventually reconstructed using bilateral stents placed with the kissing technique. Clinical examination and duplex scans or computed tomography-angiography (CT-A) were performed at discharge and 1, 6, and 12 months after the procedure, with yearly studies thereafter. RESULTS: Kissing-stents technique was selectively used in 30 cases (69.7%); the remainder cases were treated with kissing-balloons. Major complications occurred in 2 patients (4.6%). Overall, mean hospitalization was 4.1+/-2.8 days (median 3 days). Mean follow-up was 32.4 months (range 1-84 months; median 36 months). During the follow-up, 2 patients (4.6%) died. Duplex and/or CT-A examination detected 4 re-occlusions. Primary patency rates at 12, 24, and 60 months were 92%, 85.7%, and 80.7%, respectively; overall secondary patency rate was 40/43 patients. CONCLUSIONS: We consider this approach most appropriate for patients deemed at high operative risk for conventional repair or for those who refuse surgery.

Mid-term experience with the ALN retrievable inferior vena cava filter.

OBJECTIVE: To report the mid-term results of 63 patients who received a new commercially-available retrievable vena cava filter, ALN. METHODS: Between January 2001 and October 2005, 63 patients (mean age 65 +/- 15 years) underwent placement of ALN filters. Filter removal was performed when anti-thrombotic prophylaxis was considered unnecessary or when the patient could safely resume full anticoagulant therapy. RESULTS: Thirty-five patients (55%) had ilio-femoral venous thrombosis and 28 patients (45%) had ilio-caval thrombosis. Overall, 49% had pulmonary embolism. Technical success for filter insertion was 100%, without any complications. None of the procedures aborted or was converted due to technical difficulties. After a median follow-up of 21-months (range 1-48, median 18), there were no cases of pulmonary embolism or vena cava thrombosis. Two patients died of a cause unrelated to deep venous thrombosis during the follow-up period, without clinical evidence of pulmonary embolism or filter-associated complications. No device migration was observed. There were 20 (31.7%) retrieval attempts: in 16 cases filters were retrieved successfully, but 4 cases were aborted. The mean implantation period of the retrieved filter was 179 days (range 53-370). CONCLUSION: Our results confirm the clinical efficacy of the ALN filter for preventing potentially fatal pulmonary embolism whilst implanted and in absence of post-insertion complications, even when left in place indefinitely.

Intentional coverage of the left subclavian artery during endovascular stent graft repair for thoracic aortic disease.

BACKGROUND: Surgical revascularization of the left subclavian artery (LSA) has been performed to warrant arm perfusion and to prevent paraplegia during thoracic stent graft (SG) procedures. We retrospectively investigated the outcome after intentional occlusion of the left subclavian artery during SG repair for thoracic aortic diseases. METHODS: From December 2000 to June 2005, 11 patients (mean age, 57 +/- 19 years) with a short (<1 cm) proximal aspect of a thoracic aortic lesion underwent intentional LSA coverage to expand the proximal landing zone for SG fixation. Three patients were treated in the emergency setting. We did not perform a prophylactic revascularization of the LSA prior to SG implantation. A preliminary balloon occlusion test of the LSA was not performed in this series. The SG was positioned so that its covering was immediately distal to the left common carotid artery. RESULTS: SG implantation was technically successful in all patients. Intraoperative mortality was not observed; no patient suffered any impairment of left carotid artery flow. Aortography after SG implantation showed no direct flow in the LSA and refilling of the LSA via the ipsilateral vertebral artery. After the intervention, mean systolic pressure in the left arm decreased by 38 +/- 17 mmHg. The stented length of the aorta was 171 +/- 73 (median, 150). During hospitalization, no patient showed any signs of left arm malperfusion. Paraplegia was not observed. One patient developed transient ischemic attack. During a mean follow-up of 19 +/- 8 months (range, 3-36), all patients were completely asymptomatic and had no functional deficit or temperature differential between arms. No leakage was detected. CONCLUSION: Intentional LSA occlusion seems to be well tolerated. Prophylactic surgical maneuvers may be relegated to an elective measure after an endovascular aortic intervention when intolerable signs or symptoms of ischemia occur.