Short-term outcomes of the t-Branch off-the-shelf multibranched stent graft for reintervention after previous infrarenal aortic repair

OBJECTIVE

The purpose of this study was to evaluate the outcome of t-Branch (Cook Medical, Bloomington, Ind) stent graft for the treatment of thoracoabdominal and pararenal aortic aneurysms in patients who had previous infrarenal aortic repair.

METHODS

A retrospective two-center study was undertaken. All consecutive patients who underwent endovascular repair using t-Branch stent graft after previous infrarenal aortic repair between January 2010 and August 2018 were included. Demographics, past medical history, cardiovascular risk factors, and intraoperative and perioperative details were recorded. Technical success and early (30-day) mortality, morbidity, target vessel patency, and presence of endoleak were analyzed. During the first year of follow-up, survival, freedom from reintervention, and patency rates were recorded.

RESULTS

There were 32 patients (mean age, 74 ± 7 years; 81% male) included in the study; 24 (75%) patients had prior open surgical repair, and 8 (25%) patients had undergone standard endovascular aneurysm repair. The index operation was performed 9 ± 5 years earlier, including 10 ± 5 years for open surgical repair and 8 ± 6 years for endovascular aortic repair. The indication was progression of the disease in 26 patients (81%) and type IA endoleak in 6 patients (19%). The total number of target vessels incorporated was 117 arteries (3.8 ± 0.6 target vessels per patient). Eleven patients had only three vessels incorporated; celiac trunk was occluded in three patients, and eight patients had one functioning kidney. Technical success rate was 97% (31/32). There was a single technical failure in one patient who had a type IA endoleak after endovascular repair with suprarenal fixation. The stenotic right renal artery was not catheterized at the initial procedure, and retrograde access was achieved through a right subcostal incision 3 days later with successful completion of the repair. Early mortality rate was 13%, and spinal cord ischemia rate was 22% (7/32); four patients had permanent and three had transient neurologic deficits. Early target vessel patency was 100%, and the rate of any endoleak was 9% (3/32); two patients had type II endoleaks and one patient had type III endoleak. The mean follow-up was 5.4 ± 5.9 months. The cumulative survival rate was 82% and 73% at 6 and 12 months, respectively. The freedom from aorta-related mortality was 92% at 6 and 12 months. The cumulative freedom from reintervention during follow-up was 90% at 6 and 12 months. The overall target vessel patency rate was 100% and 97.5% at 6 and 12 months, respectively.

CONCLUSIONS

The use of t-Branch off-the-shelf stent graft for the treatment of aortic disease in patients who had previous infrarenal aortic repair appears to be feasible, with acceptable early outcomes in terms of morbidity and mortality.

Pilot screening program for lower extremities atherosclerotic disease in a population of central Greece

BACKGROUND

Screening program in lower extremity atherosclerotic disease (LEAD) has not been widely implemented from health systems. The aim of this study was to assess the incidence of LEAD in Greece though a pilot LEAD screening program.

METHODS

Males >60 years old without known diagnosis of LEAD or chronic renal disease were invited through public primary health care institutions to participate in a pilot screening program in Central Greece. Demographics, atherosclerotic risk factors and other comorbidities were recorded. LEAD was defined as ankle-brachial pressure index (ABPI) of <0.9 or >1.4.

RESULTS

Among a total of 1152 individuals (invitation acceptance 70%; 1152/1638) LEAD was detected in 13% (148); including 7% with ABPI<0.9 and 6% with ABPI>1.4. Comparing the groups with ABPI<0.9 vs. normal ABPI, abnormal ABPI was associated with older age (P=0.001), hypertension (HT) (P=0.037), smoking (P=0.002), duration of smoking (P=0.01), packs/year (P=0.002), coronary artery disease (P=0.02), chronic obstructive pulmonary disease (P=0.028) and cerebrovascular disease (P=0.001). After multivariate analysis, increased age (0.94, CI: 0.026-5.2; P=0.022), history of HT (2.4, CI: 0.44- 3.7; P=0.05) and longer duration of smoking (0.9, CI: 0.01-6.1; 0.013) were associated with ABPI <0.9. Abnormally higher ABPI (>1.4) was not associated with any factor. Among those without known CAD or CVD (96/148), 37.5% (36/96) were on statins and 21% (20/96) on antiplatelets.

CONCLUSIONS

Incidence of LEAD was 13% in a male >60 years-old population of central Greece; these individuals maybe undertreated. ABPI<0.9 was diagnosed in 7% and was associated with older age, HT and duration of smoking.

Cervical, anal and oral HPV detection and HPV type concordance among women referred for colposcopy

BACKGROUND

Infection with human papillomaviruses (HPVs) can cause benign and malignant tumours in the anogenital tract and the oropharynx both in men and women. The aim of the presented study was to investigate cervical, anal, and oral HPV-detection rates among women referred to colposcopy for abnormal Cervical Cancer (CaCx) screening results and assess the concordance of HPV-types among these anatomical sites.

METHODS

Women referred to colposcopy at a single centre due to abnormal cytology, conducted for CaCx screening, were subjected to cervical Liquid-based Cytology (LBC) smear testing, anal and oral sampling. Routine colposcopy consisted in multiple biopsies and/or Endocervical Curettage (ECC). HPV-detection was performed by PCR genotyping in all three anatomical sites. In high-risk (hr) HPV-DNA positive samples either from anal canal or oral cavity, anal LBC cytology and anoscopy were performed, or oral cavity examination respectively. Descriptive statistics was used for the analysis of HPV-detection rates and phi-coefficient for the determination of HPV-positivity concordance between the anatomical sites.

RESULTS

Out of 118 referred women, hr. HPV-DNA was detected in 65 (55.1%), 64 (54.2%) and 3 (2.5%) at cervix, anal canal and oral cavity respectively while low-risk HPV-DNA was detected in 14 (11.9%) and 11 (9.3%) at cervix and anal canal respectively. The phi-coefficient for cervix/anal canal was 0.392 for HPV16, 0.658 for HPV31, 0.758 for HPV33, - 0.12 for HPV45, 0.415 for HPV52 and 0.473 for HPV58. All values were statistically significant (p < 0.001).

CONCLUSIONS

The results suggest that most HPV-types, high-risk and low-risk, detected in the cervix of women with prevalent cervical dysplasia, correlate with the ones detected in their anal canal. This particularly applies for the HPV-types included in the nonavalent HPV-vaccine (HPVs 6/11/16/18/31/33/45/52/58).

The effect of Endovascular Aneurysm Repair on Renal Function in Patients Treated for Abdominal Aortic Aneurysm

Aim:

The effect of endovascular aneurysm repair in patients treated for abdominal aortic aneurysm has not been clearly defined. The objective of the present article was to provide a contemporary literature review and perform an analysis to determine the effect of EVAR on renal function in the early post-operative period and during follow-up.

Methods:

A systematic review of the literature was undertaken to identify all studies reporting the effect of EVAR on renal function. Outcome data were pooled and combined overall effect sizes were calculated using fixed or random-effects models.

Results:

Thirty-two studies reporting on 24846 patients were included. Acute renal failure after EVAR occurred with an estimated frequency of 9% (95%CI: 5-16%; I2=97%). Median follow-up period was 19.5 months (range 1-60 months). The estimated frequency of chronic renal failure during follow-up was 7% (95%CI: 3-17%; I2=98%). Hemodialysis was required in 2% (1-3%; I2=97%) of the cases.

Conclusion:

High-level evidence demonstrating the effect of EVAR on the incidence of acute and chronic renal failure is lacking. Based on the current available data, nearly 10% of patients undergoing EVAR for AAA have an increased risk for renal dysfunction after the procedure. Whether this deterioration may lead to a worse outcome has not been adequately proved.

Endovascular Repair Using a 7-Branch Stent-Graft for a Thoracoabdominal Aortic Aneurysm With Variant Renovisceral Artery Anatomy

Purpose: To present a case of endovascular repair using a custom-made 7-branch stent-graft for a thoracoabdominal aortic aneurysm (TAAA) in a patient with variations in the renovisceral artery anatomy. Case Report: A 70-year-old asymptomatic man presented with a 60-mm-diameter type IV TAAA. Due to severe coronary artery disease, an endovascular approach was elected. In the preoperative computed tomography angiography (CTA) scans, variations in the renovisceral artery anatomy included the common hepatic and splenic arteries deriving separately from the aorta and bilateral double renal arteries (RAs). A custom-made 7-branch stent-graft was manufactured to preserve all renovisceral arteries. The 7 branches were catheterized and connected with a steerable sheath from a femoral access. All branches were bridged to the target vessel (TV) with a self-expanding covered stent; 4 TVs also had balloon-expandable covered stents implanted. Final angiography and predischarge CTA showed patency of all 7 target vessels and corresponding visceral organs, with no endoleak. The patient was discharged on postoperative day 8 without complications. Six-month follow-up CTA demonstrated exclusion of the TAAA and patency of all 7 target vessels. Conclusion: Successful treatment of a TAAA in a patient with multiple variant renovisceral arteries was feasible with a custom-made 7-branch stent-graft, achieving a good early outcome.

Carotid Intima-Media Thickness and Circulation Markers of Inflammation in Patients With Depression

Objective:

Growing evidence indicates that depressive disorders (DDs) are an important risk factor for atherosclerosis. The aim of this study was to evaluate the presence of common carotid artery (CCA) intima-media thickness (IMT) and circulation inflammation markers in patients with DD.

Methods:

A cross-sectional prospective study was undertaken comparing 40 patients with DD to 40 individuals free of depression, matched for age and gender. The Beck Depression Inventory questionnaire, serum total cholesterol, triglycerides, high-sensitivity C-reactive protein, interleukin-6, tumor necrosis factor α, P-selectin, and E-selectin levels were measured. The CCA-IMT was assessed with duplex sonography.

Results:

Patients with DD were more likely to smoke (65% vs 40%; P = .03) and have higher levels of serum total cholesterol (211 mg/dL vs 181 mg/dL; P = .010), triglycerides (138 mg/dL vs 97 mg/dL; P = .005), and P-selectin (0.87 ng/mL vs 0.61 ng/mL; P = .05) and lower levels of interleukin 6 (4.4 ± 2.1 pg/mL vs 10.3 ± 1.1 pg/mL; P = .002). The CCA-IMT was similar in both groups (0.07 ± 0.02 cm vs 0.06 ± 0.01 cm; P = .31). Among those with CCA-IMT in the upper quartile, subjects in the DD group had lower levels of interleukin 6 ( P = .05) and triglycerides ( P = .01) and higher levels of soluble P-selectin ( P = .03).

Conclusion:

Patients with DD do not present with higher CCA-IMT than a control group, although smoking and a higher level of serum lipids are present. Inflammatory biomarkers seem to be higher in patients with DD.

Anatomical Differences Between Intact and Ruptured Large Abdominal Aortic Aneurysms

Purpose: To compare different anatomical characteristics between intact and ruptured large abdominal aortic aneurysms (rAAA >80 mm) with the goal of refining the process of estimating rupture risk. Materials and Methods: A retrospective study involving 62 male patients with large (>80 mm) aneurysms matched for age and smoking produced a 31-patient elective group with a mean maximum aneurysm diameter of 92±9.7 mm and a 31-patient rAAA group (mean maximum aneurysm diameter 95.7±12 mm). Preoperative computed tomography angiography scans were analyzed with a dedicated workstation, and anatomical characteristics of the aortic neck, iliac arteries, and aneurysm were compared in multivariable regression analyses; the outcomes are given as the odds ratio (OR) with 95% confidence interval (CI). The prognostic utility of several characteristics as predictors of rupture occurrence was examined with receiver operating characteristic (ROC) curves. Results: Anatomical characteristics differing significantly between elective and ruptured aneurysms were the infrarenal aortic neck diameters at 5 mm, 10 mm and 15 mm; the neck length and calcification; the common iliac artery (CIA) lengths; the iliac artery indexes; the left CIA and external iliac artery diameters; and the total and true lumen aneurysm volumes. Intraluminal thrombus (ILT) volume did not differ (p=0.76), although its distribution in elective vs ruptured cases did [absent: 0% vs 19%, respectively (p=0.025); circumferential: 61% vs 35%, respectively (p=0.04)]. Total aneurysm volume was higher in rAAA (442±140 mL) vs intact AAA (331±143 mL, p=0.014), while the ILT/total aneurysm volume rate was lower in rAAA (55%) vs intact AAA (70%, p=0.02). Multivariate analysis determined that a shorter left CIA (OR 1.07, 95% CI 1.01 to 1.1, p=0.016) and a smaller total aneurysm volume (OR 1.007, CI. 1.001 to 1.014, p=0.016) were associated with intact AAA. After a ROC curve analysis, left CIA length <50 mm demonstrated a lower incidence of rupture (sensitivity 60% and specificity 78%), while total aneurysm volume <380 mL had 60% sensitivity and specificity. Conclusion: Large rAAAs seem to have different anatomical characteristics than similarly sized intact AAAs. Large intact AAAs have lower total aneurysm volumes and shorter left CIAs, with higher ILT/aneurysm volume rates.