Outcome after acute und subacute TEVAR in uncomplicated type B aortic dissection

Objective

In the past years, a paradigm shift from best medical therapy to early thoracic endovascular aortic repair (TEVAR) has been observed in the treatment of uncomplicated type B aortic dissection (uTBAD). We aimed to analyze outcomes after TEVAR in the acute and subacute phase of uTBAD, focusing on aortic remodeling.

Methods

Retrospective analysis of consecutive patients who underwent TEVAR for acute or subacute uTBAD in two tertiary referral centers from 2008 – 2017. Two assessors per center reviewed computed tomography scans of each patient at presentation, at one year and at the last follow-up using post-processing software.

Results

Forty-nine patients were treated with TEVAR for uTBAD. The indication for TEVAR was the presence of multiple morphologic predictors of adverse aortic outcome. The most common predictors were a false lumen diameter of > = 22mm in 76% of patients, a primary entry tear of > = 10mm in 69% and a total aortic diameter of > = 40mm in 67%. There were no in-hospital deaths and no deaths at 1 year. The median follow-up was 40.6 months. Three-year cumulative survival was 94 % (46/49). Fourteen secondary interventions were performed in 10 patients (20 %) after a median of 4.2 months. TEVAR lead to remodeling of the descending thoracic aorta with a median reduction of the total aortic diameter of 4.5 mm within one year and stable diameters after three years. The median maximum false lumen diameter diminished from 26 mm to 15 mm in one year (at 3 years: 14.8 mm).

Conclusion

In this cohort of selected patients with uTBAD and multiple morphologic predictors of worse aortic outcome, elective acute or subacute TEVAR was associated with a low mortality and positive aortic remodeling in the mid-term follow-up.

[Vascular anomalies. Part II: vascular malformations]

Vascular malformations are congenital vascular anomalies with normal endothelial turnover, which can affect the whole vessel tree (arterial, capillary or lymphatic) both as isolated defects or as part of a syndrome. Developmental errors during embryogenesis, such as abnormal signaling processes that control the apoptosis, maturation and growth of vascular cells, lead to the persistence of vascular plexus cells with some degree of differentiation. Vascular malformations are usually present at birth, although symptoms or complications may be manifested later. Since the overwhelming majority are symptomatic, treatment is indicated which is often aimed only at improving the symptoms by controlling the size.

[Vascular anomalies. Part I: vascular tumors]

Vascular anomalies represent a spectrum of structural disorders and inborn errors of vascular morphogenesis, which may affect the entire arterial and venous vascular tree. They are divided into two major categories: tumors, which exhibit endothelial hyperplasia and malformations, which have normal endothelial turnover unless disturbed. Depending on their nature and complexity they can range from a simple "birthmark" to life-threatening entities. The relatively low incidence (4-10%) of vascular anomalies among the general population combined with the fact that their management often falls within the purview of several different medical and surgical specialties, has traditionally resulted in insufficient expertise in the management of these conditions. Therefore, accurate identification, a uniform nomenclature and a multidisciplinary approach are paramount for correct management.

Endovascular Stent-Anchored Aortic Grafts: A Comparison between Self-Expanding and Balloon-Expandable Stents in Minipigs

Purpose:

To study endovascular graft attachment with self-expanding Gianturco Z-stents and balloon-expanded Palmaz stents and the effect of these devices on the renal ostia.

Methods:

Ten stent-grafts were constructed, 5 with Gianturco Z-stents and 5 with Palmaz stents. The endografts were implanted under fluoroscopic guidance into the abdominal aorta of 10 pigs so that the uncovered portion of the proximal stent extended over the renal artery orifices. Distal aortic blood pressure and flow were measured before and after graft placement and 1 hour postprocedure. The aorta was then exposed surgically, and the central portion of the stent-graft was inspected through an aortotomy to assess perigraft leakage.

Results:

Stent-graft implantation was accurate and hemostatic in all cases, despite longitudinal folding of the graft due to oversizing. However, transverse folds produced pressure gradients (> 15 mmHg) between the ends of the graft in two cases. In another case, a pressure gradient resulted from partial thrombosis of the graft. In two cases, renal artery occlusion and thrombosis occurred due to coverage by the graft material. In two other animals, one of the renal arteries was entirely uncovered by a stent. The remaining 16 renal arteries were covered by the proximal stent but not the graft, as intended. One (6.25%) of these arteries thrombosed, but the remainder were grossly patent when the animals were sacrificed at 1 hour.

Conclusions:

Both Palmaz and Gianturco Z-stents produced hemostatic endovascular graft attachment, even in the presence of moderate graft oversizing. The risk of acute renal artery occlusion from juxtarenal stenting does not appear to be prohibitive, but longer term observations are needed.

Endovascular AAA Exclusion: Will Stents with Hooks and Barbs Prevent Stent-Graft Migration?

Purpose:

To investigate if stents with hooks and barbs will improve stent-graft fixation in the abdominal aorta.

Methods:

Sixteen- to 24-mm-diameter Dacron grafts were deployed inside cadaveric aortas. The grafts were anchored by stents as in endovascular abdominal aortic aneurysm repair. One hundred thirty-seven stent-graft deployments were carried out with modified self-expanding Z-stents with (A) no hooks and barbs (n = 75), (B) 4 5-mm-long hooks and barbs (n = 39), (C) 8 10-mm-long, strengthened hooks and barbs (n = 19), or (D) hooks only (n = 4). Increasing longitudinal traction was applied to determine the displacement force needed to extract the stent-grafts. The radial force of the stents was measured and correlated to the displacement force.

Results:

The median (interquartile range) displacement force needed to extract grafts anchored by stent A was 2.5 N (2.0 to 3.4), stent B 7.8 N (7.4 to 10.8), and stent C 22.5 N (17.1 to 27.9), p < 0.001. Both hooks and barbs added anchoring strength. During traction, the weaker barbs were distorted or caused intimal tears. The stronger barbs engaged the entire aortic wall. The radial force of the stents had no impact on fixation, while aortic calcification and graft oversizing had marginal effects.

Conclusions:

Stent barbs and hooks increased the fixation of stent-grafts tenfold, while the radial force of stents had no impact. These data may prove important in future endograft development to prevent stent-graft migration after aneurysm exclusion.

Abdominal Aortic Aneurysms: Experience with the Ivancev-Malmö Endovascular System for Aortomonoiliac Stent-Grafts

Purpose:

To describe a component-based aortomonoiliac stent-graft system and the first clinical results achieved with this device in endovascular abdominal aortic aneurysm (AAA) repair.

Methods:

From November 1993 to October 1996, 45 patients aged 60 to 86 years underwent endoluminal exclusion of true AAAs (median diameter 60 mm) involving the common iliac arteries (median diameter 16 mm right and 15 mm left) using unilimb stent-grafts deployed with the Ivancev-Malmö system.

Results:

Six immediate conversions occurred in the beginning of the series due to endografts that were too short. Complications, including 2 inadvertent renal artery occlusions, 7 kinked grafts, 6 iliac artery dissections, and 3 perioccluder leaks, were prominent features in the first 15 patients. Five patients died in the postoperative period, four of whom were nonsurgical candidates. There were five significant stent-graft migrations: one 3 weeks after surgery due to mechanical injury of the proximal stent and four after 1 year owing to continuous dilation of a wide proximal neck, stent-graft placement in a conical, thrombus-lined proximal neck, and two instances of proximal extension separation from the main graft. Translumbar aneurysm perfusion required embolization in 3 patients.

Conclusions:

Despite early complications associated with a learning curve, exclusion of large AAAs using unilimb stent-grafts is feasible. Strict inclusion criteria are necessary in order to improve mortality among nonsurgical candidates and minimize the risk for late migration.

Late Aortic Arch Perforation by Graft-Anchoring Stent: Complication of Endovascular Thoracic Aneurysm Exclusion

Purpose:

To describe a fatal case of late aortic perforation by an endograft-anchoring stent.

Methods and Results:

A 69-year-old woman presented 2 years after thoracoabdominal aneurysm repair with a 9-cm dilatation of the descending thoracic aorta proximal to the conventional aortic graft. A 38-mm Dacron graft with multiple Gianturco Z-stents sutured inside was placed transluminally across the aortic arch such that part of the uncovered portion of the proximal stent was partially across the left subclavian orifice. Four months later, the patient died from massive hemorrhage. Autopsy showed that the uncovered portion of the proximal stent had perforated the aortic arch.

Conclusions:

This case stresses the need for low-profile stent-grafts and smaller, more flexible introducer systems. Anchoring stents must be flexible, less traumatic, and strong enough to create a watertight seal even in tortuous vessels. To avoid aortic arch damage by thoracic stent-grafts, the proximal stent should be fully covered by the fabric.

Impairment of erectile function after elective repair of abdominal aortic aneurysm

The purpose of the present study was to compare the functional change of erectile dysfunction after endovascular repair (EVAR) and open repair (OR) of abdominal aortic aneurysm.

Between April 2009 and December 2011, male patients admitted for elective treatment of an asymptomatic infrarenal abdominal aortic aneurysm were included. The erectile function was evaluated by using a validated KEED questionnaire. All patients filled out the questionnaire preoperatively and postoperatively after one year.

The number of patients with an increase of erectile dysfunction was 8 (26.6%) to 16 (53.3%) in open repair group vs. 30 (42.6%) to 40 (58.8%) in endovascular aneurysm repair. There was no statistically significant difference between open repair and endovascular aneurysm repair groups in order of new incidence of erectile dysfunction ( p = 0.412). The study showed an increase in the mean value of Erectile Dysfunction -Score postoperatively in both the groups as well.

The present study showed an increase of erectile dysfunction postoperatively, but the difference between the two groups was not statistically significant.

Endovascular repair of acute uncomplicated aortic type B dissection promotes aortic remodelling: 1 year results of the ADSORB trial

OBJECTIVES

Uncomplicated acute type B aortic dissection (AD) treated conservatively has a 10% 30-day mortality and up to 25% need intervention within 4 years. In complicated AD, stent grafts have been encouraging. The aim of the present prospective randomised trial was to compare best medical treatment (BMT) with BMT and Gore TAG stent graft in patients with uncomplicated AD. The primary endpoint was a combination of incomplete/no false lumen thrombosis, aortic dilatation, or aortic rupture at 1 year.

METHODS

The AD history had to be less than 14 days, and exclusion criteria were rupture, impending rupture, malperfusion. Of the 61 patients randomised, 80% were DeBakey type IIIB.

RESULTS

Thirty-one patients were randomised to the BMT group and 30 to the BMT+TAG group. Mean age was 63 years for both groups. The left subclavian artery was completely covered in 47% and in part in 17% of the cases. During the first 30 days, no deaths occurred in either group, but there were three crossovers from the BMT to the BMT+TAG group, all due to progression of disease within 1 week. There were two withdrawals from the BMT+TAG group. At the 1-year follow up there had been another two failures in the BMT group: one malperfusion and one aneurysm formation (p = .056 for all). One death occurred in the BMT+TAG group. For the overall endpoint BMT+TAG was significantly different from BMT only (p < .001). Incomplete false lumen thrombosis, was found in 13 (43%) of the TAG+BMT group and 30 (97%) of the BMT group (p < .001). The false lumen reduced in size in the BMT+TAG group (p < .001) whereas in the BMT group it increased. The true lumen increased in the BMT+TAG (p < .001) whereas in the BMT group it remained unchanged. The overall transverse diameter was the same at the beginning and after 1 year in the BMT group (42.1 mm), but in the BMT+TAG it decreased (38.8 mm; p = .062).

CONCLUSIONS

Uncomplicated AD can be safely treated with the Gore TAG device. Remodelling with thrombosis of the false lumen and reduction of its diameter is induced by the stent graft, but long term results are needed.

Introduction of embryonic stem cells into vein grafts reduces intimal hyperplasia in mice

AIM

Atherosclerosis with its cardiovascular events including cardiac and peripheral ischemia represents the main cause of death in the developed countries. Although interventional treatments like percutaneous transluminal angioplasty or stents are increasingly applied for the treatment of peripheral arterial disease, they are not always technically applicable or durable and bypass surgery is needed. Compared to synthetic grafts, vein grafts show a better patency especially when used for the lower leg as well as a lower risk for infection compared to synthetic grafts. Still the long-term patency rates are unsatisfactory due to accelerated intimal hyperplasia, a thickening of the vessel wall. The aim of this study was to elucidate, if the implantation of embryonic stem cells into vein grafts can reduce the development of intimal hyperplasia in a mouse in vivo model.

METHODS

In this study we implanted LacZ-tagged (ROSA26) murine embryonic stem cells into decellularized vein grafts. Control groups were: 1) untreated veins; 2) decellularized veins; 3) decellularized veins with gel and plastic film; and 4) decellularized veins with smooth muscle cells in gel surrounded by plastic film. Six weeks after insertion into the carotid artery of mice, the grafts were excised and analyzed immunohistochemically, morphologically, and by x-gal staining and compared to the control groups. The Mann-Whitney U test was used to compare groups. Statistical significance was indicated by a value of P<0.05.

RESULTS

Decellularized veins with implanted stem cells showed significantly less intimal thickening compared to all control groups (intimal hyperplasia vs. luminal circumference mean±SD 7.3±3.5 µm, median 8 µm). The control groups: 1) untreated veins (60.3±25.5 µm, median 58.5 µm); 2) decellularized veins (53.9±22.4 µm, median 48.4 µm); 3) decellularized veins with gel and plastic film (70.6±22.4 µm, median 72.6 µm); and 4) decellularized veins with smooth muscle cells in gel surrounded by plastic film (73.5±18.1 µm, median 73.6 µm) all showed the same high degree of intimal hyperplasia.

CONCLUSION

This study demonstrates that embryonic stem cells have a therapeutic competence to favourably modulate intimal hyperplasia in vivo.

[Metaanalysis of EVAR versus open repair for patients undergoing elective repair of abdominal aortic aneurysms]

INTRODUCTION

Elective endovascular abdominal aneurysm repair (EVAR) has become established in the past 20 years as a therapy option for infrarenal abdominal aortic aneurysms (AAA). Even so the benefits of EVAR over open aneurysm repair (OR) are still being discussed controversially.

MATERIALS AND METHODS

A random effects meta-analysis model was used to compare the surgical outcome of EVAR with that of open operations. The end points were evaluated comparatively by use of the Peto odds ratio (Peto OR) and weighted mean differences (WMD). Four prospective randomised studies (EVAR-1, DREAM, OVER, ACE) with a total of 2747 patients (EVAR 1381, OR 1366) were included in the metaanalysis.

RESULTS

In comparison to OR, EVAR was associated with a significantly reduced 30-day mortality rate (Peto OR: 0.373; p<0.001). In addition, there was a statistically significant advantage of EVAR over OR with regard to aneurysm-associated mortality (Peto OR: 0.589, p=0.013) and the length of hospital stay (SD in mean: -0.494; p<0.001). In contrast OR exhibited a lower re-intervention rate than EVAR (Peto OR: 1.843, p<0.001). On consideration of long-term survival (Peto OR: 0,977; p=0.826) and health-related quality of life there were no statistically significant differences between the two therapeutic options (SD in mean: - 0.032, p=0.481).

CONCLUSIONS

In spite of the clinical heterogeneity of the studies included in the metaanalysis, the data indicate that EVAR has a marked benefit with regard to surgical mortality. In the long-term course this advantage in survival is lost but this is not due to the aneurysm-associated mortality.

Novel chimney-graft technique for preserving hypogastric flow in complex aortoiliac aneurysms

We describe the feasibility and result of a novel approach to preserve pelvic perfusion during endovascular aortoiliac aneurysm repair (EVAR) in patients with aortoiliac aneurysms extending to the iliac bifurcation. The iliac chimney-graft technique consists of the deployment of a ViaBahn™ graft into the hypogastric artery in combination with standard abdominal aortic stent-grafts. The chimney graft was deployed using a transsubclavian access and placed parallel with the iliac limb into the standard aortic stent graft, which was deployed directly before. The technical procedure was successful. Postoperative control showed a sufficiently excluded aneurysm without evidence of endoleak and good distal perfusion of both iliac arteries. The CT-scan after 6 months confirmed the result. The chimney-graft stent grafts to maintain perfusion to hypogastric arteries are feasible and provide an alternative to hypogastric artery exclusion or branched grafts. Long-term follow-up is needed to evaluate stent-graft patency and failure rates.

Triple-barrel graft as a novel strategy to preserve supra-aortic branches in arch-TEVAR procedures: clinical study and systematic review

OBJECTIVE

To report our early experience with total endovascular repair of aortic-arch aneurysm using double chimney-grafts and present a literature overview.

PATIENTS AND METHODS

The double chimney-graft technique was performed in six male patients with contained ruptured aneurysm, dissecting aneurysm, pseudoaneurysm, penetrating aortic ulcer and proximal endoleak after TEVAR. Furthermore, a systematic electronic health database search of available articles was conducted according to PRISMA Guidelines.

RESULTS

In all cases, all supra-aortic vessels had to be covered with aortic stent-graft to receive a sufficient landing and sealing zone. Chimney-grafts were introduced to the ascending aorta slightly deeper than the thoracic stent-grafts through the cut-down exposure of the common carotid arteries. We deployed aortic stent-grafts and self-expandable chimney-grafts simultaneously and successfully. The patient with contained ruptured aneurysm died due to cardiopulmonary failure on day 19, the others survived. We detected two 'gutter' endoleaks. As a result of literature search, 12 articles met the inclusion criteria. Two articles described the double-chimney technique.

CONCLUSIONS

The use of double chimney-grafts is possible in high-risk patients where the proximal landing zone of endograft would be in zone 0. The available data is still limited. The long-term follow-up remains to be evaluated with the increased number of patients treated.

[Is there a role for risk-scoring methods in ruptured abdominal aortic aneurysm (rAAA)?]

BACKGROUND

Rupture of an abdominal aortic aneurysm (rAAA) is associated with a high mortality both before and after admission to hospital. In spite of the use of expensive intensive medical therapeutic interventions 30 - 50 % of the operated patients still die. The ASA score is one of the most used scores world-wide. Use of the Glasgow aneurysm score (GAS) and the Hardman index (HI) is frequently reported in the literature to predict survival after surgical management of rAAA. With regard to the comorbidity factor severity score (CSS) no evaluated data on the mortality in cases of rAAA are available. On the basis of our own patient collective we intended to assess to what extent the risk score could give an answer to the question of therapeutic options.

METHODS

In a retrospective study (7/1998 - 8/2007), 94 patients (m : f = 78 : 16) were assessed after operative management of rAAA. The validity of preoperative risk assessments on the basis of the ASA score, the CSS, the GAS and the HI with regard to intra- or postoperative death in the initial hospitalisation period was examined. Sensitivity and specificity of the score systems were determined by receiver operating characteristics (ROC) analyses.

RESULTS

The age of the patients was 72.3 ± 9.5 years (mean ± SD). Thirty-five (37.2 %) patients died in the immediate postoperative period. The areas under the receiver operating characteristics curves for ASA, GAS, HI and CSS were 0.598, 0.787, 0.742 and 0.614, respectively.

CONCLUSIONS

This study revealed clear differences in the prognostic predictions of the various scores. In accord with the literature, no score gave a 100 % positive result with regard to mortality. Thus, an individual decision or, respectively, a therapeutic option cannot be reached with the help of the investigated scores. Further parameters need to be evaluated in order to make decisions about postoperative therapy.

Buttock Claudication After Interventional Occlusion of the Hypogastric Artery—A Mid-Term Follow-Up

Background. Interventional occlusion of the hypogastric artery (HA) can be used for endovascular aneurysm repair (EVAR) in the iliac arteries. Most frequent ischemic complication is buttock claudication (BC). Aim. To investigate the frequency and progression of BC after interventional occlusion of the HA prior to EVAR. Methods. A retrospective analysis was performed in patients with EVAR and occlusion of the HA between September 2004 and August 2010. Acute and persistent BC symptoms were assessed. Results. Fifty-four catheter occlusions of the HA were performed. In 10 cases, claudication could not be evaluated. During a mean follow-up of 17 months, 23 occlusions (52.3%) of the HA showed BC, in 52% symptoms were persistent. Of the 5 patients, 3 patients who underwent bilateral occlusion had BC and in 2 cases, persistent in the follow-up. Conclusion. Buttock claudication after occlusion of the HA prior to EVAR is a frequent complication, which often persists during follow-up. Alternatives that maintain pelvic perfusion should be considered.

Cordis INCRAFT™ ultra-low profile AAA stent-graft system

Endovascular repair was originally introduced as a less invasive alternative in less healthy patients, but potentially lower morbidity has been balanced by limited anatomic applicability, as well as inferior long-term device durability. The INCRAFT™ endograft was developed with surgical repair in mind, in an attempt to capitalize on the anatomic flexibility of traditional procedures. The INCRAFT system was designed to address durability issues of older generation devices. At the same time it provides a solution for a broad range of patients using a limited number of codes needed. The 3-pieces modular system allows precise placement at level of the iliacs and aortic neck reducing the risk of unintentional coverage of the hypogastric and renal arteries. In addition, the ultra-low profile delivery system (13 Fr even for graft main bodies up to 30 mm) contributes to increase patient eligibility for endovascular aortic repair and to decrease the risk for access complications. When desired, the delivery system can be introduced through a percutaneous approach. The initial experience with the new endograft showed a highly versatile device that offers a more individualized endovascular option to a greater number of patients with abdominal aortic aneurysms. The ongoing IN-NOVATION trial and two planned clinical trials (IN-CEPTION and IN-SPIRATION) will build further understanding of the performance of the device allowing for a wider subset of inclusion criteria.

Outcome of patients with open and endovascular repair in acute complicated type B aortic dissection: a systematic review and meta-analysis of case series and comparative studies

AIM

Acute complicated type B aortic dissection is a life-threatening condition. We summarized all published studies for TEVAR among patients with acute complicated typ B aortic dissection (TBAD) with respect to clinical success, complications, and outcomes. Furthermore, we determined whether TEVAR reduces death and morbidity compared with open repair for TBAD.

METHODS

Studies were identified from a literature search using various databases, and included studies when three or more patients were reported and at least in-hospital mortality was reported. Data from comparative studies of TEVAR versus open repair of the descending aorta in TBAD were combined through meta-analysis.

RESULTS

Seventy-six observational studies involving 1951 patients were included in the present meta-analysis. In-hospital mortality was 11.5% and other major complications (i.e., stroke (6.3%), paraplegia (4.9%), retrograde type A aortic dissection (7%), renal impairment including dialysis (6.9%), bowel infarction (4.1%), vascular problems including major amputation (2.5%)) occurred less frequently. Long-term follow-up was limited to a mean of 24 months. During this time, endovascular reintervention was required in 11.3%, surgical reintervention in 7.7%, and late aortic rupture was calculated for 3.2% of cases. A complete false lumen thrombosis was estimated to occur in 76.1% of cases. In comparative studies, 30-day/in-hospital mortality (OR=0.256, P=0.001) and paraplegia/paraparesis (OR=0.256, P=0.001) were significantly reduced for TEVAR versus open repair. In addition to that, the rate of vascular complications was reduced for TEVAR (OR=0.373, P=0.036). There was no significant difference between TEVAR and open repair in patients with acute complicated TBAD for the following outcomes: late mortality, reintervention rate, renal dysfunction (including dialysis), and stroke rate.

CONCLUSION

This summary analysis suggests that endovascular treatment of complicated acute type B aortic dissection produces favourable initial outcomes and would seem to be a great addition to the treatment options for this condition. Further study of long-term outcomes is required.

Comparison of CE approved TEVAR devices

The indications for endovascular therapy of thoracic aortic pathologies are expanding. The complexity of cases is increasing. The individual anatomy and pathology of the thoracic aorta alone and in combination create specific difficulties in stent graft delivery, deployment, and fixation. Graft design has evolved, and several new iterations of stent grafts have been introduced into clinical practice. The assessment of these new grafts is difficult, due to the changing indications for their use and a lack of large-scale clinical trials. Currently, a number of thoracic stent graft devices are available in Europe. Variable amounts of clinical data are available to support their use.

Outcome of carotid endarterectomy under local anaesthesia with respect to the patients' risk profile

BACKGROUND

In the present study the perioperative complication rate is compared between high- and low-risk patients when carotid endarterectomy (CEA) is routinely performed under local anaesthesia (LA).

PATIENTS AND METHODS

From January 2000 through June 2008 1220 consecutive patients underwent CEA under LA. High-risk patients fulfilled at least one of the following characteristics: ASA 4 classification, "hostile neck", recurrent ICA stenosis, contralateral ICA occlusion, age > or = 80 years. The combined complication rate comprised any new neurological deficit (TIA or stroke), myocardial infarction or death within 30 days after CEA, which was compared between patient groups.

RESULTS

Overall 309 patients (25%) were attributed to the high-risk group, which differed significantly regarding sex distribution (more males: 70% vs. 63%, p = 0.011), neurological presentation (more asymptomatic: 72% vs. 62%, p = 0.001) and shunt necessity (33% vs. 14%, p < 0.001). In 32 patients 17 TIAs and 15 strokes were observed. In 3 patients a myocardial infarction occurred. Death occurred in one patient following a stroke and in another patient following myocardial infarction, leading to a combined complication rate of 2.9% (35/1220). In the multivariate analysis only previous neurological symptomatology (OR 2.85, 95% CI 1.38-5.91) and intraoperative shunting (OR 5.57, 95% CI 2.69-11.55) were identified as independent risk factors for an increased combined complication rate.

CONCLUSIONS

With the routine use of LA, CEA was not associated with worse outcome in high-risk patients. Considering the data reported in the literature, it does not appear justified to refer high-risk patients principally to carotid angioplasty and stenting (CAS) when LA can be chosen to perform CEA.

Meta-analysis of subfascial endoscopic perforator vein surgery (SEPS) for chronic venous insufficiency

Objectives

The degree of benefits and risks, and the role of subfascial endoscopic perforator vein surgery (SEPS) in the management for chronic venous insufficiency (CVI) remains uncertain.

Methods

A multiple health database search was performed including Medline, Embase, Ovid, Cochrane Database of Systematic Reviews, and Cochrane Database of Abstracts of Reviews of Effectiveness, on all studies published between 1985 and 2008 that reported on health outcomes in patients with CVI treated with SEPS and comparing this therapy with the conventional Linton procedure. Three studies, which compared SEPS with conventional surgery, were included in the present meta-analysis.

Results

Between SEPS and Linton groups, there was a significant lower rate of wound infections for SEPS (odds ratio [OR] 0.06 [95% confidence interval (CI) 0.02 to 0.25]) and a significantly reduced hospital stay for SEPS (OR –8.96 [95% CI –11.62 to –6.30]). In addition, SEPS was associated with a significant reduced rate of recurrent ulcers (mean follow-up 21 months) (OR 0.15 [95% CI 0.04–0.62]). There was no significant difference between the groups in the following dimensions: rate of hospital re-admission (OR 0.21 [95% CI 0.03 –1.31]), death at six months (OR 3.00 [95% CI 0.11–78.27]), ulcer healing rate at four months (OR 0.44 [95% CI 0.09–2.12]), and the rate of deep vein thrombosis (DVT) (OR 0.35 [95% CI 0.01–8.85]).

Conclusion

From the level of evidence available by now it seems that SEPS, used as a part of a treatment regimen for severe CVI, benefits most patients in the short term regarding ulcer healing and the prevention of ulcer recurrence. It can be safely performed with less early postoperative complications compared with the Linton procedure. However, further prospective randomized trials are required to define the long-term benefits of SEPS.

Meta-analysis of transilluminated powered phlebectomy for superficial varicosities

AIM

The purpose of the present meta-analysis was to analyze the data available concerning the transilluminated powered phlebectomy (TIPP).

METHODS

A multiple electronic health database search was performed including Medline, Embase, Ovid, Cochrane Database of Systematic Reviews, and Cochrane Database of Abstracts of Reviews of Effectiveness (DARE), on all studies published between 1996 and 2007 that reported about health outcomes in patients with cardiovascular insufficiency (CVI) treated with TIPP and comparing this therapy with the conventional procedure. Five studies, that compared TIPP with conventional surgery, were included in the present meta-analysis.

RESULTS

Currently, these data clearly proved significant statistical advantage of TIPP technique over the conventional treatment, only for number of incisions, mean cosmetic score and duration of the procedure. However, TIPP technique seemed to be faster only for extensive varicose veins. There was, however, a significantly reduced incidence of calf hematoma after hook phlebectomy compared to TIPP, and TIPP procedure was associated with a worse mean pain score.

CONCLUSION

Further randomized trials are needed to determine the benefit of this procedure.

How to design the optimal stent graft--what have we learnt?

It is now more than 20 years since the first report of stent graft insertion in the human arterial system was published. The first "homemade" devices proved that the technique was possible but could not show any durability. Using these devices, it was possible to get a good seal but not a good anchorage. Not even the first generation of commercially available stent grafts proved to be durable. First after gaining knowledge about the forces acting on the stent graft, it was realized that attachment was important for the durability and the hooks and barbs or a longitudinal stability are needed to minimise the risk for distal migration. Not much of a difference in the overall performance is noticed between the ePTFE graft or the polyester graft or when comparing stainless steel stents with those made out of nitinol. The systems are made much more flexible and hydrophilic leading to a better performance and a greater chance of percutaneous approach. The optimal stent graft is not out on the market yet, but hopefully will come with further development.

When is safe to cover the left subclavian and celiac arteries. Part II: celiac artery

Endovascular repair of thoracic and thoraco-abdominal aortic aneurysms became apparent as an alternative to open repair. When the distal landing zone proximal to celiac artery is inadequate, a traditional open surgical approach with thoracoabdominal aortic replacement concomitant with visceral and renal bypasses is necessary. Alternatively, either an abdominal hybrid procedure with debranching of the visceral vessels with subsequent thoracic stent graft placement or complete endovascular aneurysm exclusion with branched stent grafts is required. Extending the distal landing zone might be possible by covering the celiac artery origin. In this article, the authors review the anatomy of the celiac artery (SA) and the superior mesenteric artery (SMA) and consequences of CA coverage as scenery for a discussion of the ramifications of CA coverage during endovascular thoracic aortic repair (TEVAR). Summarizing the currently available literature, we will demonstrate the feasibility of covering the celiac artery based on a diagnostic algorithm.

When is safe to cover the left subclavian and celiac arteries. Part I: left subclavian artery

Over the last 15 years the endovascular repair of thoracic aortic pathologies has been developing as the treatment of choice, but it requires appropriate anatomy. Proximal and distal landing zones are essential for fixation and sealing. In order to extend the proximal landing zone for the stent-graft and achieve an adequate seal, the left subclavian artery (LSA) is often covered, with or without concomitant subclavian artery revascularization. In this article the authors review the LSA anatomy and consequences of LSA coverage as scenery for a discussion of the ramifications of LSA coverage during endovascular thoracic aortic repair (TEVAR). Summarizing the currently available literature, the authors reveal that there is no consensus regarding a preparatory left carotid-subclavian bypass or a transposition of the left subclavian artery to the left common carotid artery. Various management strategies are offered.

Systematic review and meta-analysis of endovenous radiofrequency obliteration, endovenous laser therapy, and foam sclerotherapy for primary varicosis

AIM

Radiofrequency obliteration (RFO), endovenous laser therapy (EVLT) and foam sclerotherapy (FS) are potential treatments for varicose veins. A systematic review was undertaken to assess their safety and effectiveness and to compare these endoluminal therapeutic options with conventional ligation and vein stripping.

METHODS

An electronic health database search was performed on all studies published between 1970 and 2007 describing RFO, EVLT, and FS for treating varicose veins.

RESULTS

Twenty-nine EVLT studies, 32 RFO studies and 22 FS trials were included. RFO was associated with the worst short and long-term safety and efficacy results compared to EVLT and FS regarding ''complete occlusion at the end of follow-up'', ''phlebitis'', ''deep vein thrombosis'', and ''paraesthesia''. EVLT had the best results concerning the long-term effectiveness parameters for ''occlusion at the end of follow-up'' and ''recanalization, recurrence or development of new veins'', compared to RFO and FS. Foam sclerotherapy of varicose veins is associated with a higher recurrence rate in patients with saphenofemoral incompetence compared to the rates after EVLT or RFO treatment.

CONCLUSION

EVLT, RFO, and FS seem to be safe and effective modalities with good short and mid-term

RESULTS

Acquisition of comparative long-term and very long-term data on clinical efficacy (particularly with regard to the formation of recurrent varicose veins), safety, quality of life outcomes and costs is needed by large high-quality prospective randomized trials of endovenous techniques versus each other and versus surgery before considering endovenous techniques as the standard treatment.

[The role of intra-operative Prostavasin application during crural bypass surgery]

INTRODUCTION

The aim of this study was to evaluate the role of intra-operative Prostavasin application during crural bypass surgery. 68 Patients, who underwent infrainguinal autologous vein bypass surgery, were prospectively analyzed.

RESULTS

Intra-operative flow measurements and Prostavasin administration were performed in all patients. The mean flow was 105 ml / min (minimal flow 18 ml / min, maximal flow 321 ml / min). The means of maximal and minimal flow were 329 und 30 ml / min, respectively. The mean of the calculated Pulsatility index was 3.1. The mean flow volume increased after administration of Prostavasin in all patients with a mean increase of 103 %. The Pulsatility index decreased by 39 %. Primary and secondary patency rates after 1 year were 70.3 % und 73.1 %, respectively. The differentiated analyses of the region of the distal anastomoses (popliteal / crural) showed a statistically significant bigger increase of Q after Prostavasin application for infrainguinal popliteal bypasses compared to patients with crural reconstructions (p = 0.05). In addition, the decrease of the Pulsatility index was significantly higher in popliteal grafts (p = 0.03). Patients with early bypass graft failure showed a significantly smaller decrease of PI after Prostavasin application compared to the other patients.

CONCLUSION

The profit of intra-operative arterial Prostavasin application is first of all an immediate one. The injection of Prostavasin leads to an instant vessel dilatation. This allows the surgeon to get an impression of the flow capacity of the bypass. The Pulsatility index as an indicator for resistance is an important factor for bypass patency.

Evaluation of Changes of Systemic Blood Pressure and Shunt Incidence in CEA

BACKGROUND

Induced hypertension is widely recommended as a protective measure in carotid endarterectomy (CEA) to prevent shunt insertion. In this study changes of systemic blood pressure were evaluated in relation to the shunt rate when CEA was performed under local anaesthesia.

MATERIALS AND METHODS

In 930 CEAs performed for a high-grade (>70%) ICA stenosis under local anaesthesia the mean systemic blood pressure was measured preoperatively (RR1) and directly before carotid cross-clamping (RR2). A ratio was calculated from these values (RRR=RR2/RR1). A shunt was only inserted for clinical signs of cerebral ischemia. If that became necessary later after cross-clamping had been tolerated primarily, the blood pressure during this period was also recorded (RR3). Also the presence of a contralateral ICA occlusion and baseline blood pressure levels were considered as factors with potential impact on shunt necessity.

RESULTS

Among the 638 male (69%) and 292 female (31%) patients with a median age of 70 years (ranging from 52 to 91 years) 82 (9%) had a contralateral ICA occlusion. A shunt was used in 177 operations (19%) and significantly more frequent in patients with a contralateral ICA occlusion (39/82=48% vs. 138/848=16%, p<0,001). RRR was significantly reduced in patients who needed a shunt (0.95 (0.41-1.53) vs. 1.0 (0.54-1.9), p=0.002) which was only true for patients with a patent contralateral ICA. The shunt rate did not differ when contrasting RRR thresholds (<0.7 vs. >1.3) or preoperative blood pressure levels (<100 mmHg vs. >120 mmHg) were compared. RRR did not differ between directly or delayed shunted patients. RR3 did not differ significantly from RR2. A regression analysis identified the presence of a contralateral ICA occlusion as the only independent parameter influencing shunt insertion.

CONCLUSIONS

Changes in systemic blood pressure during CEA under local anaesthesia seem to influence shunting rather marginally. The value of induced hypertension to prevent cerebral ischemia should be newly discussed.

Combined Endovascular–Open Surgical Procedure in a Great Hepatic Artery Aneurysm

Visceral artery aneurysms are rare lesions. They involve the hepatic artery in approximately 20% of cases. Various therapeutic options are available for patients with hepatic artery aneurysms (HAAs). Dictated predominately by the need to maintain distal end-organ perfusion, potential therapies include traditional surgical techniques and laparoscopic surgery, endovascular methods of embolization, and stenting of the lesions. There is still a lack of studies demonstrating the comparative efficacy or inefficacy of any particular treatment, so there are currently no precise indications for determining which type of treatment should be used. In this paper, we present a case of great HAA in a 59-year-old man. He was preoperatively diagnosed and treated with a combined surgical and endovascular approach. The clinical presentation, management, and therapy of patients with HAAs are discussed. In addition to that, we reviewed the literature dealing with HAAs. This case report lays emphasis on the aspect that the treatment strategy in HAAs has to be determined individually in each case due to the high anatomic variability of the arterial supply of the liver. Treatment with a combined surgical and endovascular approach may reduce the risk of liver ischemia and morbidity.

Meta-analysis of Randomized Trials Comparing Carotid Endarterectomy and Endovascular Treatment

OBJECTIVE AND DESIGN

In order to evaluate the comparative efficacy and safety of carotid angioplasty with or without stent placement (CAS) versus carotid endarterectomy (CEA) we performed a meta-analysis of the presently available randomized studies.

MATERIALS AND METHODS

A multiple electronic health database search on all randomized trials describing CAS compared with CEA in patients with symptomatic or asymptomatic carotid artery stenosis was performed.

RESULTS

Seven trials totalling 2972 patients (1480 randomized to CEA and 1492 randomized to CAS) were included in the meta-analysis. Results significantly favoured CEA over CAS in terms of death or any stroke at 30 days after procedure; the risk of death, any stroke, or myocardial infarction at 30 days; ipsilateral ischaemic stroke at 30 days; any stroke at 30 days; death or stroke at 6 months; and the risk of procedural failure. There was a significantly reduced risk of cranial neuropathy at 30 days after CAS. There was no significant difference between CAS and CEA groups in the odds of death or disabling stroke at 30 days, death or stroke at 1 year after the procedure, and ipsilateral intracerebral bleeding at 30 days.

CONCLUSIONS

The results of this meta-analysis suggest that CEA can be performed with more safety than CAS. As a result, CEA remains the "gold standard" treatment for suitable de novo carotid stenosis and CAS should only be performed within randomized trials of stenting versus surgery.

[Prophylaxis of contrast-induced nephropathy with N-acetylcysteine]

PURPOSE

Clinical trials evaluating N-acetylcysteine (NAC) for the prevention of radiocontrast-induced nephropathy (RCN) have reported mixed results. Despite formerly published meta-analyses and due to currently published RCTs, time has come to re-evaluate the current evidence of preventing RCN by administering NAC.

METHODS

We performed a computerized search without restricted to a language to identify relevant published randomized clinical trials that evaluated N-acetylcysteine for the prevention of radiocontrast-induced nephropathy. Abstracted data from each trial included assessments of clinical outcomes, trial quality, and additional characteristics. The primary outcome of interest was the incidence of nephropathy after contrast administration. Data were combined using random effects models with the performance of standard tests to assess for heterogeneity and publication bias. Subgroup analyses were also performed.

RESULTS

Twenty-eight trials involving 3 604 patients met our inclusion criteria. Trials varied in patient demographic characteristics, inclusion criteria, dosing regimens, and trial quality. The summary risk ratio for contrast-related nephropathy was 0.69 (95 % confidence interval: 0.57 to 0.82; P = 0.02), a statistically significant trend towards benefit in patients treated with N-acetylcysteine. This effect varied, however, across the 28 trials, and only eight of the 28 trials demonstrated significant results although higher-quality trials demonstrated a stronger benefit for N-acetylcysteine in general, few reported important elements of study design, such as concealment of allocation, placebo-controls, or double-blinding. Heterogenity was unexplained by subgroup analyses.

SUMMARY AND CONCLUSIONS

N-acetylcysteine (NAC) may reduce the incidence of contrast-related nephropathy, but this finding is reported inconsistently across currently available trials. Large high-quality, clinical trials are needed before the application of N-acetylcysteine can be recommended in general for this indication.