Long-Term Outcomes of Open and Endovascular Abdominal Aortic Repair in Younger Patients.

BACKGROUND: Aim of this study is to evaluate long-term results in abdominal aortic aneurysm (AAA) surgery by either open aortic repair (OAR) or endovascular aortic repair (EVAR) in patients under 70 years of age. METHODS: A retrospective analysis of a prospectively collected database of patients with age under 70 years old undergoing elective infrarenal AAA surgery between 2010 and 2018 was performed. The study population was divided into 2 groups: OAR and EVAR. Primary end points were overall survival and aneurysm-related death, while secondary outcomes were need for reintervention and development of minor and major complications. RESULTS: One hundred ninety-one patients younger than 70 years old treated with elective AAA surgery were enrolled: 157 OAR (98% males, mean age 65 ± 4 years) and 34 EVAR (94% males, mean age 66 ± 4 years). Hospital stay, 30-day mortality, and need for reintervention were similar; OAR population presented higher incidence of postoperative major complications (18% vs. 2.9%; P = 0.01) while minor complications were 32% in the OAR versus 21% in the EVAR group (P = 0.08). Median follow-up was 69 months for OAR (interquartile range [IQR] 53 months) vs. 79 months (IQR 51 months) for EVAR (P = 0.9): long-term AAA-related reinterventions were more frequent after EVAR (1.9% OAR vs. 17% EVAR; P = 0.01) while AAA-related long-term mortality was similar in both subgroups (1.3% OAR and 3% EVAR; P = 0.8). At univariate analysis higher risk of reintervention was reported for conical necks in the EVAR group (P = 0.03) and for the concomitant presence of iliac aneurysms in both groups (P = 0.01). CONCLUSIONS: According to our data, EVAR in young patients is presenting an excessive rate of reintervention compared to OAR. The presence of conical neck is an independent predictor of EVAR failure and late reintervention, while it does not play a significant role in the OAR group. Open surgery should be considered the first option in younger patients with a long-life expectancy.

Oxygen Delivery Therapy with EPIFLO Reduces Wound Hyperperfusion in Patients with Chronic Leg Ulcers: A Laser Speckle Contrast Analysis.

BACKGROUND: Today transdermal continuous oxygen therapy (TCOT) is used in wound care to promote healing by improving local hypoxia and preventing infection, and it has been described to reduce local inflammation over 1 month of administration. The present study aims to investigate the effects of this treatment on wound microcirculation through laser speckle contrast analysis (LASCA). METHODS: 20 adult patients (mean age: 76 ± 11.5 years) were prospectively enrolled. Inclusion criteria were presence of venous or mixed lower limb ulcers from three or more months without dimension reduction and without indication to surgery and weekly treatment by our outpatient clinic with silver dressings. Subjects underwent 1 month of TCOT (EPIFLO®) in addition to foam dressing. The primary endpoint was the comparison of ulcer and healthy skin perfusion through LASCA, performed before and after the treatment period. Secondary considered endpoints were wound area, wound area severity index and PUSH Tools 3.0 ulcer severity scales, and pain assessment (Numerical Rating Scale [NRS]). RESULTS: Before treatment, the wound area was significantly more perfused than healthy skin (+45%; P = 0.005). At the end of the study, this difference was not significant anymore (+20.5%; P = 0.11). Ulcer perfusion decreased (-12.5%, P = 0.047), whereas healthy skin perfusion did not vary significantly. A reduction of the wound dimension (median difference: 2 cm; P = 0.009) and pain (median difference: 2 NRS point; P < 0.001) after therapy were assessed. CONCLUSIONS: LASCA shows that 1 month of TCOT can help reduce hyperperfusion of ulcer bed in patients with chronic lower limb ulcers, strengthening the hypothesis that this treatment effectively contrasts inflammation. This could correlate with the area and pain reduction assessed; however, the absence of a control group in this study does not allow a generalization of this hypothesis. Larger, controlled trials are needed to properly assess the relationship between TCOT effects on wound microenvironment and effective healing process.

Angioplasty or bare metal stent versus drug-eluting endovascular treatment in femoropopliteal artery disease: a systematic review and meta-analysis.

INTRODUCTION: Endovascular treatment represents nowadays the preferred therapeutic approach for disabling femoro-popliteal arterial occlusive disease in fit patients. In the latest years, in order to improve short- and long-term outcomes, drug eluting devices have been developed. Drug coated balloons (DCB) and drug eluting stents (DES) are today employed in clinical practice, and several studies has been completed to assess their performance in different clinical scenarios. Objective of the present review and meta-analysis is to compare clinical results of different endovascular treatment modalities in the published literature in the last 10 years. EVIDENCE ACQUISITION: A systematic review and meta-analysis following the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) statement on the literature regarding direct comparisons between DCB, DES, bare metal stents (BMS) and Plain Old Balloon Angioplasty (POBA) has been conducted. Primary outcomes were considered Primary Patency and Target Lesion Revascularization (TLR) at 12 months. Analysis of late survival in different treatment groups was outside the scope of the present study and was therefore not included as main end point. EVIDENCE SYNTHESIS: Meta analysis results confirm that DCB outperforms POBA in both primary patency (estimate OR=3.17, 95% CI: 2.10-4.76) and TLR (POBA estimate OR=3.59, 95% CI= 2.31-5.56). No clear evidences emerged comparing DES and BMS; however, DES were shown to fare better than BMS in terms of TLR when analyzing lesions <15 cm (OR 0.36, 95% CI: 0.35-0.36). Comparison of DCB and DES revealed higher rates of TLR for DES (OR 1.26 95% CI: 1.07-1.49), however no significant differences have been found regarding primary patency analyzing such long lesions (range 14-19.4 cm) as those included in the studies. CONCLUSIONS: While confirming that DCB outperforms POBA in terms of primary patency and TLR at 12 months, only TLR benefits are noted for DES vs. BMS and DCB vs. DES in limited clinical settings. Further RCTs are needed to strongly assess the compared performance of drug eluting devices in relation to lesion length and controlling possible confounders.

Impact of the Supra-Aortic Trunks and Circle of Willis Patency on the Neurological Compensation during Carotid Endarterectomy.

BACKGROUND: One of the most critical phases of carotid endarterectomy (CEA) is the carotid cross-clamping test, which is a concrete evaluation of efficacy of collateral cerebral perfusion. Some studies revealed a strong correlation between tolerance to carotid cross-clamping and postoperative transient ischemic attack (TIA)/stroke complications. The aim of the study is to make a global analysis of supra-aortic trunks (SAT) and circle of Willis (CoW) patency to predict the tolerance to carotid cross-clamping preoperatively. METHODS: We observed retrospectively 503 patients who underwent CEA under local anesthesia between January 2012 and 2017. We analyzed single preoperative risk factors, drug therapy, and vessels patency of the group of patients who did or did not present neurological symptoms at carotid cross-clamping. Afterward, we created a cerebral perfusion score (PTOT) to estimate the efficacy of collateral cerebral perfusion and we compared the results from both groups. The score ranges from 0 (hypothetical total occlusion of the SAT and CoW) to 0.65 in case of patency of all arterial districts. Moreover, we evaluated postoperative complication rates. RESULTS: Patients with previous neurological symptoms, female gender, and diabetes correlate with a lower tolerance to carotid cross-clamping (odds ratio: 2.57, 2.78, and 2.57, respectively; P value < 0.05). The SAT and CoW score revealed that patients with score <0.2 more frequently did not tolerate carotid cross-clamping (P value 0.01). Patients who required an intraoperative shunt presented a higher risk of TIA/stroke within 30 days from surgery than those with a better neurological compensation (P value 0.03). CONCLUSIONS: The efficacy of cerebral mechanisms of compensation during carotid cross-clamping reflects the capability of the brain to adapt to ischemic insults, and this also correlates with the postoperative risk of TIA/stroke. It is possible to identify preoperatively patients with a higher risk of neurological intolerance at carotid cross-clamping. This score could be a useful method to make a further stratification of risk of neurological complications and eventually to prefer a general anesthesia and the use of shunt for those with PTOT < 0.2.

A Rare Nitinol Double-Layer Micromesh Carotid Stent Complication: Late Thrombosis-First Case Reported in Literature.

Endovascular treatment of carotid artery stenosis is a valuable alternative to open surgery, and the evolution of stent materials and cerebral protection devices significantly decreased postoperative neurological complications. Among these, the introduction of nitinol double-layer micromesh stent seems to guarantee a reduced perioperative and postoperative cerebral embolization. Long-term results are however still not available to make a global evaluation of these stents. We present the case of a 66-year-old female patient treated for asymptomatic carotid stenosis complicated by a symptomatic partial stent thrombosis occurred three months after carotid artery stenting.

Carotid Pseudoaneurysm After Eversion Endarterectomy: A Case Report and Review of the Literature.

BACKGROUND: Pseudoaneurysm (PA) after carotid endarterectomy (CEA) is a rare and potentially life-threatening complication, with an incidence lower than 1%. Most of the cases described report PAs after carotid patch angioplasty and are associated with infection, often caused by Staphylococci. The management of PAs can be surgical, endovascular, or hybrid. METHODS: We herein present the case of an infected carotid PA 27 days after an eversion CEA. We performed a common to internal carotid bypass with the interposition of great saphenous vein (GSV) associated with specific polyantibiotic therapy for 4 weeks. We searched the PubMed database for reviews and cases reports for patients who developed carotid PA after primary repair CEA in the period between 1969 and 2017. RESULTS: We identified 21 cases of primary closure post-CEA PAs in the literature. In almost 60% of patients, infection was detected. Open surgery was performed in all the cases; in 1 case, an hybrid approach was preferred. In 52% of cases, a vein graft/patch or primary closure was chosen; in 3 cases, ligation was preferred, and in 1 case, a polyester graft was used. CONCLUSION: In our experience and with the evidence observed in the literature, open surgery with GSV interposition is the safest treatment in infected carotid PAs. The endovascular approach must be performed only in proven noninfectious cases. A bridge technique with the insertion of a stent followed by open surgery repair can be an option in emergency cases.

The Endovascular Management of an Iatrogenic Superior Gluteal Artery Rupture Following Bone Marrow Biopsy.

We herein report an uncommon case of a life-threatening retroperitoneal hematoma after a bone marrow biopsy. Two hours after iliac crest bone harvesting, the patient experienced syncope and severe hypotension. Urgent contrast-enhanced computed tomography demonstrated extravasation from the superior gluteal artery. Transcatheter coil embolization was performed successfully, without complications. Life-threatening complications caused by retroperitoneal bleeding after bone marrow biopsy are very rare. There are few reports on the use of endovascular treatment in the management of life-threatening hemorrhagic complications after bone marrow biopsy.

Severe Mesenteric Ischemia in a Pregnant Woman with Antiphospholipid Syndrome.

The antiphospholipid syndrome (APS), either primary or secondary form, is considered an autoimmune disease with the presence of at least 1 clinical and 1 laboratory abnormalities as defined by the Sydney criteria. Clinical criteria include vascular thrombosis of venous, artery, small vessel in any organ, and recurrent pregnancy pathologies. Mesenteric ischemia is a rare and threatening manifestation of APS. We herein report a case of a 34-year-old pregnant woman referred to our Emergency Room with thoracic and abdominal acute pain. Her past medical history was remarkable for positivity to antiphospholipid antibodies, deep vein thrombosis of the right lower limb, chronic occlusion of celiac trunk, and superior mesenteric artery and recurrent abortions. Imaging revealed acute occlusion of inferior mesenteric artery (IMA). Both a surgical and endovascular thrombectomy were ineffective to obtain durable IMA patency and so the patient underwent antegrade aorta-inferior mesenteric bypass with saphenous vein and resection of an ischemic ileal loop. The medical treatment at discharge was lifelong oral anticoagulant associated with double antiplatelet therapy. To the best of our knowledge, this is the first case reporting a young pregnant woman with APS and mesenteric ischemia submitted to several attempts of revascularization. Aggressive oral anticoagulant and antiplatelet long-term therapy is advised. Moreover, we recommend strict follow-up in those patients in order to early diagnose thrombotic recurrence.

Stent-assisted detachable coil embolization of wide-necked renal artery aneurysms.

Renal artery aneurysms (RAAs) are rare with an estimated incidence of 0.1% in the general population, and they represent approximately 25% of all visceral aneurysms. The gold standard of treatment is open surgery, but it is associated with a high risk of nephrectomy, mortality, and morbidity. Less invasive endovascular therapies are becoming increasingly common for the treatment of RAAs. Here, we aimed to report three cases of wide-necked complex renal artery aneurysms treated endovascularly using stent-assisted coil embolization with self-expandable stent nitinol Solitaire AB and Concerto Axium coils. In addition, we describe the use of the waffle-cone technique in a case of wide-necked saccular RAA involving the renal artery bifurcation. Technical success was achieved in all three cases with no early or late complications and no recurrences.

Endovascular treatment of spontaneous isolated abdominal aortic dissection.

Isolated abdominal aortic dissection is a rare clinical disease representing only 1.3% of all dissections. There are a few case series reported in the literature. The causes of this pathology can be spontaneous, iatrogenic, or traumatic. Most patients are asymptomatic and symptoms are usually abdominal or back pain, while claudication and lower limb ischemia are rare. Surgical and endovascular treatment are two valid options with acceptable results. We herein describe nine cases of symptomatic spontaneous isolated abdominal aortic dissection, out of which four successfully were treated with an endovascular approach between July 2003 and July 2013. All patients were men, smokers, symptomatic (either abdominal or back pain or lower limb ischemia), with a history of high blood pressure, with a medical history negative for concomitant aneurysmatic dilatation or previous endovascular intervention. Diagnosis of isolated abdominal aortic dissection were established by contrast-enhanced computed tomography angiography (CTA) of the thoracic and abdominal aorta. All nine patients initially underwent medical treatment. In four symptomatic cases, non-responsive to medical therapy, bare-metal stents or stent grafts were successfully positioned. All patients completed a CTA follow-up of at least 12 months, during which they remained symptom-free. Endovascular management of this condition is associated with a high rate of technical success and a low mortality; therefore, it can be considered the treatment of choice when it is feasible.

Giant true Brachial Artery Aneurysm after Hemodialysis Fistula Closure in a Renal Transplant Patient.

The usual manifestation of brachial artery aneurysms is the incidental finding of a swelling of the arm, combined with paresthesia or pain in some cases. The etiology is often traumatic or secondary to drug abuse. Pathophysiology of brachial artery dilation in these cases is not completely clear. We herein describe a case of a 61-year-old male presenting with a giant, painful, pulsatile mass on his left arm. He was submitted to a cadaveric kidney transplant in 2005. He had a functioning arteriovenous fistula (AVF) on his right arm, and a spontaneously thrombosed radiocephalic AVF on his left arm. The aneurysm was surgically resected, sparing the median nerve that was totally entrapped and an inverted segment of the basilic vein interposed. At the follow-up, the patient did not present neurological or ischemic disturbs, and the vein graft maintained its patency.

Pre and postoperative evaluation of transcranial Doppler pulsatility index of the middle cerebral artery in patients with severe carotid artery stenosis.

UNLABELLED: In the management of severe carotid artery stenosis particular importance must be given to the evaluation of the risk of perioperative cerebral ischemic events. Our study analysed the possible relationship between the pre-operative middle cerebral artery Gosling Index, calculated after transcranial Doppler (TCD), and intra-operative stump pressure (SP), in order to identify patients with higher risk of ischemic accidents. Moreover, we studied pre- and post- operative Gosling Index values in association with possible events during follow-up. In a one-year time lapse 47 patients underwent either carotid endoarterectomy (CEA) or carotid artery stenting (CAS) with proximal embolic protection system. All patients were subject to pre- and post-operative TCD with calculation of the Gosling Index and intra-operative SP. We observed that higher pre-operative Gosling Index values are associated with lower intra-operative SP values, elements that represent a higher risk for cerebro-vascular ischemic accidents; this result is particularly evident when observing the diabetic sub-population. An increase in ischemic events did not present statistically significant differences when observing the populations treated with CEA or CAS. TCD and SP are valid and simple exams that can help identify precociously patients with a higher risk of cerebro-vascular accidents related to surgical or endovascular treatment. KEY WORDS: Carotid artery stenosis, Carotid endarterectomy, Endovascular treatment.