The empty pelvis syndrome: a core data set from the PelvEx collaborative

BACKGROUND

Empty pelvis syndrome (EPS) is a significant source of morbidity following pelvic exenteration (PE), but is undefined. EPS outcome reporting and descriptors of radicality of PE are inconsistent; therefore, the best approaches for prevention are unknown. To facilitate future research into EPS, the aim of this study is to define a measurable core outcome set, core descriptor set and written definition for EPS. Consensus on strategies to mitigate EPS was also explored.

METHOD

Three-stage consensus methodology was used: longlisting with systematic review, healthcare professional event, patient engagement, and Delphi-piloting; shortlisting with two rounds of modified Delphi; and a confirmatory stage using a modified nominal group technique. This included a selection of measurement instruments, and iterative generation of a written EPS definition.

RESULTS

One hundred and three and 119 participants took part in the modified Delphi and consensus meetings, respectively. This encompassed international patient and healthcare professional representation with multidisciplinary input. Seventy statements were longlisted, seven core outcomes (bowel obstruction, enteroperineal fistula, chronic perineal sinus, infected pelvic collection, bowel obstruction, morbidity from reconstruction, re-intervention, and quality of life), and four core descriptors (magnitude of surgery, radiotherapy-induced damage, methods of reconstruction, and changes in volume of pelvic dead space) reached consensus-where applicable, measurement of these outcomes and descriptors was defined. A written definition for EPS was agreed.

CONCLUSIONS

EPS is an area of unmet research and clinical need. This study provides an agreed definition and core data set for EPS to facilitate further research.

Superior mesenteric artery-related outcomes in fenestrated/branched endografting for complex aortic aneurysms

Aim

Early/follow-up durability of superior mesenteric artery (SMA) stent-grafts is crucial after fenestrated/branched endografting (FB-EVAR) in complex abdominal aortic aneurysms (CAAAs) and thoracoabdominal aortic aneurysms (TAAAs). The study aimed to report early/midterm outcomes of SMA incorporated during FB-EVAR procedures.

Methods

FB-EVAR procedures performed between 2016 and 2021 in a single institution were reviewed. Anatomical SMA characteristics were analyzed. The SMA configuration was classified into three types according to the angle between the SMA main trunk and the aorta: (A) perpendicular, (B) downward, and (C) upward. SMA-related technical success (SMA-TS: cannulation and stenting, patency at completion angiography without endoleak, stenosis/kinking, dissection, bleeding, and 24-h mortality) and SMA-adverse events (SMA-AEs: one among bowel ischemia, stenosis, occlusion, endoleak, reinterventions, or SMA-related mortality) were assessed.

Results

Two hundred FB-EVAR procedures with SMA as the target artery were performed. The indication for FB-EVAR was CAAAs and TAAAs in 99 (49%) and 101 (51%) cases, respectively. The SMA configuration was A, B, and C in 132 (66%), 63 (31%), and 5 (3%) cases, respectively. SMA was incorporated with fenestrations and branches in 131 (66%) and 69 (34%) cases, respectively. Directional branch (P < .001), aortic diameter ≥35 mm at the SMA level (P < .001), and ≥2 SMA bridging stent-grafts (P = .001) were more frequent in TAAAs. Relining of the SMA stent-graft with a bare metal stent was necessary in 41 (21%) cases to correct an acute angle between the stent-graft and native artery (39), stent-graft stenosis (1), or SMA dissection (1). Relining was associated with type A or C SMA configuration (OR: 17; 95% CI: 1.8-157.3; P = .01). SMA-TS was achieved in all cases. Overall, 15 (7.5%) patients had SMA-AEs [early: 9 (60%), follow-up: 6 (40%)] due to stenosis (2), endoleak (8), and bowel ischemia (5). Aortic diameter ≥35 mm at the SMA level was an independent risk factor for SMA-AEs (OR: 4; 95% CI: 1.4-13.8; P = .01). Fourteen (7%) patients died during hospitalization with 10 (5%) events within the 30-postoperative day. Emergency cases (OR: 33; 95% CI: 5.7-191.3; P = .001), peripheral arterial occlusive disease (OR: 14; 95% CI: 2.3-88.8; P = .004), and bowel ischemia (OR: 41; 95% CI: 1.9-87.9; P = .01) were risk factors for 30-day/in-hospital mortality. The mean follow-up was 32 ± 24 months; estimated 3-year survival was 81%, with no case of late SMA-related mortality or occlusion. The estimated 3-year freedom from overall and SMA-related reinterventions was 74% and 95%, respectively.

Conclusion

SMA orientation determines the necessity of stent-graft relining. Aortic diameter ≥35 mm at the SMA level is a predictor of SMA-AEs. Nevertheless, SMA-related outcomes of FB-EVAR are satisfactory, with excellent technical success and promising clinical outcomes during the follow-up.

Minimum standards of pelvic exenterative practice: PelvEx Collaborative guideline

This document outlines the important aspects of caring for patients who have been diagnosed with advanced pelvic cancer. It is primarily aimed at those who are establishing a service that adequately caters to this patient group. The relevant literature has been summarized and an attempt made to simplify the approach to management of these complex cases.

Home-based exercise in autoimmune myasthenia gravis: A randomized controlled trial

The tolerance of exercise and its effects on quality of life in myasthenia gravis are not currently backed up by strong evidence. The aim of this study was to determine whether exercise as an adjunct therapy is well tolerated and can improve health-related quality of life (HRQoL) in stabilized, generalized autoimmune myasthenia gravis (gMG). We conducted a parallel-group, multi-center prospective RCT using computer-generated block randomization. Adults with stabilized, gMG, and no contra-indication to exercise, were eligible. Participants received usual care alone or usual care and exercise. The exercise intervention consisted of 3-weekly 40 min sessions of an unsupervised, moderate-intensity home rowing program over 3 months. The primary endpoint was the change in HRQoL from randomization to post-intervention. Assessor-blinded secondary endpoints were exercise tolerance and effects on clinical, psychological and immunological status. Of 138 patients screened between October 2014 and July 2017, 45 were randomly assigned to exercise (n = 23) or usual care (n = 20). Although exercise was well tolerated, the intention-to-treat analysis revealed no evidence of improved HRQoL compared to usual care (MGQOL-15-F; mean adjusted between-groups difference of -0.8 points, 95%CI -5.4 to 3.7). Two patients hospitalized for MG exacerbation were from the usual care group.

P891Psycho-social impact of predictive genetic testing in hereditary heart diseases (PREDICT Study)

Introduction

Hereditary heart diseases are most often characterized by autosomal dominant inheritance and delayed cardiac expression. Predictive genetic testing is offered to asymptomatic relatives to allow targeted medical care with early therapeutics in order to reduce the risk of complications. Psychological issues and socio-professional impact of predictive testing are complex and have been poorly studied. The aim of this study was to evaluate the psychological and socio-professional impact of predictive genetic testing in hereditary heart diseases through a prospective and retrospective study.

Patients and methods

This multicentric French study involved 20 expert centers in hereditary heart diseases. We included 517 adult relatives (42.3±16.7 years, 60.6% females) who performed predictive genetic testing (prospective study: N=264, retrospective study: N=253). The opinion and experience were collected via auto-questionnaires, at various moments in the prospective study, with different items and validated scales (STAI: score for anxiety and IES: impact of event).

Results

In the prospective study, family history was characterized by cardiomyopathy (88.4%) and channelopathies (11.6%). The main motivations for performing the test were: “to remove doubt” (65.3%), “for children” (64.0%), “to benefit from medical supervision” (34.9%). A mutation was present in 39.4% of relatives. No regret was expressed after testing (only 2.3% regrets). The result did not lead to a socio-professional change or family relationship change in 60.7%. Among those who had a change, it was perceived as unfavorable for only 3%. A change in socio-professional status and/or family relationship was mainly related to the result of genetic testing (p<0.0001). The level of anxiety (STAI scale) increased before the test result but then decreased and returned to baseline. Subjects with depression history were more likely to develop anxiety at long term after multivariate analyses (p=0.004). Quite similar results were observed in the retrospective study.

Conclusions

Our results show that contrary to a widespread opinion, the medical benefit was not the main motivation for predictive genetic testing. In most cases, no or marginal adverse psychological and socio-professional impact of genetic testing was observed when performed by a team expert in predictive testing. However careful management is required to identify and manage subjects at risk for increased anxiety or socio-professional change.

The Management of Geriatric and Frail HIV Patients. A 2017 Update from the Italian Guidelines for the Use of Antiretroviral Agents and the Diagnostic Clinical Management of HIV-1 Infected Persons

OBJECTIVE

This article deals with the attempt to join HIV and geriatric care management in the 2017 edition of the Italian guidelines for the use of antiretrovirals and the diagnostic-clinical management of HIV-1 infected persons.

METHODS

The outlined recommendations are based on evidence from randomized clinical trials and observational studies published in peer-reviewed journals and/or presented at international scientific conferences in recent years. The principles of starting antiretroviral therapy in elderly patients and the viro-immunological goals are the same as in the general HIV population. However, there are some specificities to consider, related to the host as well as the therapy itself. HIV care in elderly patients must shift from a combined AntiRetroviral Therapy specific approach to a more comprehensive management, and from a disease-based model (list of co-morbidities) to a multi-morbidity and frailty standpoint. The implementation of a geriatric approach, based on the Comprehensive Geriatric Assessment, is essential and consists of a broader evaluation of health status. This multidimensional and multidisciplinary evaluation is focused on the development of a tailored intervention plan. Polypharmacy is a frequent condition in the older population and an independent risk factor for negative health-related outcomes. This can be overcome with a multidisciplinary and cooperative approach involving HIV specialists, geriatricians and primary care physicians.

CONCLUSION

The inclusion of geriatric care becomes necessary due to the novel needs of an evolving patient population. It is important to underline that the HIV specialist will continue to lead multidimensional interventions and optimize quality of care for HIV-positive people.

Secondary findings from next generation sequencing: Psychological and ethical issues. Family and patient perspectives

Access to active search for actionable secondary findings (SF) in diagnostic practice is a major psychological and ethical issue for genomic medicine. In this study, we analyzed the preferences of patients and their families regarding SF and identified the reporting procedures necessary for informed consent. We interviewed parents of patients with undiagnosed rare diseases potentially eligible for exome sequencing and patients affected by the diseases listed in the ACMG recommendations. Four focus groups (FG) were formed: parents of patients with undiagnosed rare diseases (FG1, n = 5); patients with hereditary cancers (FG2, n = 10); patients with hereditary cardiac conditions (FG3, n = 3); and patients with metabolic diseases (FG4, n = 3). Psychologists presented three broad topics for discussion: 1. Favorable or not to SF access, 2. Reporting procedures, 3. Equity of access. Discussions were recorded and analyzed using simplified Grounded Theory. Overall, 8 participants declared being favorable to SF because of the medical benefit (mainly FG1); 11 were unfavorable because of the psychological consequences (mainly FG2, FG3, FG4); 2 were ambivalent. The possibility of looking for SF in minors was debated. The 4 key information-based issues for participants ranked as follows: explanation of SF issues, autonomy of choice, importance of a reflection period, and quality of interactions between patients and professionals. Examining equity of access to SF led to philosophical discussions on quality of life. In conclusion, individual experience and life context (circumstances) were decisive in participants' expectations and fears regarding access to SF. Additional longitudinal studies based on actual SF disclosure announcements are needed to establish future guidelines.

Guidelines for presymptomatic testing for Huntington's disease: past, present and future in France

Huntington's disease was the first adult onset neurological disease for which presymptomatic genetic testing became possible. It served as a model for the approach which constituted a radical change in medical practice and provided an important framework for multi-step, multidisciplinary, counselling for at risk persons. We will review the historical context of guidelines and good clinical practices, the experiences of our team which covers more than 20 years of presymptomatic testing for Huntington's disease in France, and explore the impact of the new French legislation for the future of presymptomatic testing of diseases for which neither preventive measures nor curative treatments are yet available.

Proximal aortic neck angle does not affect early and late EVAR outcomes: an AnacondaTM Italian Registry analysis

AIM

The aim of this paper was to evaluate early and 3-year results of the endovascular repair (EVAR) for abdominal aortic aneurysm (AAA) using the AnacondaTM endograft in patients with severe proximal aortic neck angle.

METHODS

A retrospective analysis of the AnacondaTM Italian Registry was carried out. Two groups of patients were identified according to the presence of a severe (Group A, GA: ≥ 60°) or an absent (Group B, GB: <45°) proximal aortic neck angle. Preoperative, procedural and follow-up data were evaluated. Mortality, proximal type I endoleak, freedom from iliac leg thrombosis and conversion to open repair were analyzed at 30-day and 3-year follow-up. The results of GA and GB were compared.

RESULTS

From 2005 to 2012, 1030 patients were enrolled in the Registry. Sixty-five patients (6.3%) were included in GA and 737 (71.5%) in GB. The mean age and AAA diameter were respectively 76.8 years and 62.7 mm in GA and 77.2 years and 56.5 mm in GB (P=NS). The ASA ≥ 3 was reported in the 95.3% of GA vs. 81% of GB (P=0.005). The endograft main-body was repositioned in 35% of cases in GA and 20.7% in GB (P=0.008); there were no differences in the main-body ballooning and proximal aortic cuff placement. There were no statistical differences in 30-day mortality (GA 1.5% vs. GB 1.3%), proximal type I endoleaks (GA 1.5% vs. GB 0.8%), iliac leg thrombosis (GA 1.5% vs. GB 1.4%) and conversion to open repair (GA 3% vs. GB 0.6%). The 3-year survival was 95.4% in GA and 94.7% in GB (P=NS). Freedom from proximal type I endoleak, iliac leg thrombosis and conversion to open repair were respectively 98.5%, 95.4%, and 95.4% in GA and 97.8%, 96.9%, and 98.5% in GB (P=NS).

CONCLUSION

The AnacondaTM Italian Registry reports good results in terms of clinical success at 3-year follow-up. AAA with severe proximal aortic neck can be treated with similar outcomes to AAA with favorable neck anatomy. The endograft repositionability is a benefit in cases with severe neck angle.

Bypass to the ankle and foot in the era of endovascular therapy of tibial disease. Results and factors influencing the outcome

AIM

Endovascular therapy (ET) is the treatment of choice for critical limb ischemia (CLI) and tibial arteries disease (TAD) in focal lesions with restorable run-off; ankle and foot bypass (BPG) is indicated in patients unfit for ET with foot or ankle arteries suitable for surgery. The aim of this study was to evaluate limb salvage (LS), primary patency (PP) and survival (S) of patients underwent BPG in the era of ET for TAD and to define the correlated prognostic factors.

METHODS

Between February 2000 and November 2008, patients with CLI and TAD were collected prospectively in a data-base (demographics, Fontaine's stage, Texas University Wound Classification [TUC]of ulcers, risk-factors, TAD, techniques of foot revascularization and surgical factors). BPG was performed in tibial arteries occlusion longer than 4 cm or focal occlusion without line-flow to pedal arteries. Clinical and Duplex-ultrasound follow-up was performed at discharge, 1, 3, 6 months and every 6 months. LS, PP, and S rates were assessed with Kaplan-Meier method; factors influencing outcomes were sought by multivariate Cox proportional hazards model analysis.

RESULTS

A total of 410 revascularizations were performed in patients with CLI and TAD; BPG in 153 patients (mean age: 69.3±10.6, male/female=117/36, diabetes mellitus=75.2% hyperlypidemia=54.9%, hypertension=87.6%, renal disease=32.7%, coronary arteries disease=51.6%, Fontaine stage IV=96.1%, TUC grade-III=65.4%, TUC stage-D=51%). All autologous grafts in 96.7% (non-reversed saphenous vein=74.5%, reversed=7.2%, composite vein graft=12.4%, arm's veins=2.6%). LS and S after 1 month were 88.2% and 97.1%, respectively. Mean follow-up was 23 months. At 12 and 36 months: LS 76.7% and 70.9%, PP 62.3% and 52.9%, S 91.5% and 74.6%. LS was negatively associated with age (HR=1.041 [95%CI=1.005-1.079]), infected ulcers (HR=3.377 [95%CI=1.571-7.258]), run-off arteries diameter <1.8 mm (HR=5.854[95% CI=2.274-15.070]). PP was negatively associated with hyperlipidemia (HR=2.555 [95% CI=1.418-4.603]), female gender (HR=2.125[95% CI=1.182-3.823]), run-off arteries diameter <1.8 mm (HR=6.165 [95% CI=2.774-13.699]), reversed saphenous graft (HR=3.105 [95% CI=1.166-8.272]), composite vein graft (HR=2.930 [95% CI=1.406-6.107]) and homograft (HR=2.762 [95% CI=1.040-7.333]); instead it is positively related with hypertension (HR=4.229 [95% CI=2.089-8.563]). S was negatively correlated with renal disease (HR=3.035 [95% CI=1.363-6.756]).

CONCLUSION

BPG may be a reasonable first treatment for CLI patients with TAD unfit for ET; female gender, hyperlipidemia, use of reversed saphenous, composite vein or alternative grafts, foot infection and renal disease are associated with worse outcome.

Treatment of peripheral arterial disease in diabetes: a consensus of the Italian Societies of Diabetes (SID, AMD), Radiology (SIRM) and Vascular Endovascular Surgery (SICVE)

Diabetic foot (DF) is a chronic and highly disabling complication of diabetes. The prevalence of peripheral arterial disease (PAD) is high in diabetic patients and, associated or not with peripheral neuropathy (PN), can be found in 50% of cases of DF. It is worth pointing out that the number of major amputations in diabetic patients is still very high. Many PAD diabetic patients are not revascularised due to lack of technical expertise or, even worse, negative beliefs because of poor experience. This despite the progress obtained in the techniques of distal revascularisation that nowadays allow to reopen distal arteries of the leg and foot. Italy has one of the lowest prevalence rates of major amputations in Europe, and has a long tradition in the field of limb salvage by means of an aggressive approach in debridement, antibiotic therapy and distal revascularisation. Therefore, we believe it is appropriate to produce a consensus document concerning the treatment of PAD and limb salvage in diabetic patients, based on the Italian experience in this field, to share with the scientific community.

Attitudes and expectations of patients with neuromuscular diseases about their participation in a clinical trial

AIM

This study aimed to gain a better understanding of the psychological impact of participating in a clinical trial for patients with Pompe disease (Acid Maltase Deficiency). Attitudes and expectations of adult patients with neuromuscular diseases regarding medical trials are as yet unreported. In order to learn about the psychological consequences of participating in a clinical trial, we conducted a prospective assessment of patients with late-onset Pompe Disease, a rare genetic condition, for which no treatment had been available before. This psychological study was carried out as an ancillary study to the randomized double-blind placebo-controlled trial described elsewhere (van der Ploeg et al., 2010).

SUBJECTS AND METHODS

We assessed patients (n=8) at inclusion, and at 12 and 18 months for six psychological dimensions: depression (Beck Depression Inventory, BDI), hopelessness (Beck Hopelessness Scale, BHS), anxiety (STAI A-B), quality of life (Whoqol-26), social adjustment (S.A.S-self-report) and locus of control (IPC Levenson). We produced a self-administered questionnaire in order to assess the attitudes, motivations and expectations of patients during the trial.

RESULTS

At 12 months, mean social adjustment (SAS-SR, P=0.02) had improved, and at 18 months mean depression score had improved as well (BDI, P=0.03). The quality of life of patients (Whoqol-26) remained unchanged. Throughout the study, patients were more likely to have an internal locus of control than an external one (IPC Levenson). The self-administered questionnaire showed that patients' expectations were disproportionate compared to the medical information they had received starting the trial. For all patients, the first motivation for being enrolled in a clinical trial was "to help research", for half of them the motivation was to "improve their health". Whether patients believed to be part of one group or another (placebo or treatment) depended on their subjective perception of improvement during the trial.

CONCLUSION

Given the small sample size, the conclusions of this study are preliminary. However, findings do suggest that there is a positive psychological impact of participating in a treatment trial. Moreover, the patients' reactions upon unblinding have led us to recommend that patients be asked whether they would like their group assignation disclosed to them or not.

Contralateral carotid occlusion in endovascular and surgical carotid revascularization: a single centre experience with literature review and meta-analysis

OBJECTIVE/BACKGROUND

The influence of contralateral carotid occlusion (CCO) on the outcome of carotid endarterectomy (CEA) and stenting (CAS) is debated. This study aims to evaluate CEA and CAS results in patients with CCO.

METHODS

All carotid revascularizations from 2005 to 2011 were analyzed, focusing on the role of CCO on 30-day cerebral events and death (CED). A meta-analysis was performed to evaluate the results of the literature by random effect.

RESULTS

Of the 1,218 carotid revascularizations performed in our institution, 706 (57.9%) were CEA and 512 (42.1%) were CAS. CED occurred in 3.6% of the CEAs and 8.2% of the CASs (p = .001). CCO was present in 37 (5.2%) CEAs and 38 (7.4%) CASs. In CEA, CCO patients had a higher CED compared with the non-CCO patients (16.2% vs. 2.9%, p = .001), as confirmed by multiple regression analysis (OR [odds ratio]: 5.1[1.7-14.5]). In CAS, CED was not significantly different in the CCO and non-CCO patients (2.6% vs. 8.7%, p = 0.23). The comparative analysis of the CCO patients showed a higher CED in CEA compared with that in CAS (16.2% vs. 2.6%, p = 0.04). Meta-analysis of 33 papers (27 on CEA and 6 on CAS) revealed that CCO was associated with a higher CED in CEA, but not in CAS (OR: 1.82 [1.57-2.11]; OR: 1.22 [0.60-2.49], respectively).

CONCLUSION

CCO can be considered as a risk factor for CED in CEA, but not in CAS. CAS appears to be associated with lower CED than CEA in CCO patients.

BRAVISSIMO: 12-month results from a large scale prospective trial

The BRAVISSIMO study is a prospective, non-randomized, multi-center, multi-national, monitored trial, conducted at 12 hospitals in Belgium and 11 hospitals in Italy. This manuscript reports the findings up to the 12-month follow-up time point for both the TASC A&B cohort and the TASC C&D cohort. The primary endpoint of the study is primary patency at 12 months, defined as a target lesion without a hemodynamically significant stenosis on Duplex ultrasound (>50%, systolic velocity ratio no greater than 2.0) and without target lesion revascularization (TLR) within 12 months. Between July 2009 and September 2010, 190 patients with TASC A or TASC B aortoiliac lesions and 135 patients with TASC C or TASC D aortoiliac lesions were included. The demographic data were comparable for the TASC A/B cohort and the TASC C/D cohort. The number of claudicants was significantly higher in the TASC A/B cohort, The TASC C/D cohort contains more CLI patients. The primary patency rate for the total patient population was 93.1%. The primary patency rates at 12 months for the TASC A, B, C and D lesions were 94.0%, 96.5%, 91.3% and 90.2% respectively. No statistical significant difference was shown when comparing these groups. Our findings confirm that endovascular therapy, and more specifically primary stenting, is the preferred treatment for patients with TASC A, B, C and D aortoiliac lesions. We notice similar endovascular results compared to surgery, however without the invasive character of surgery.

Abdominal aortic aneurysms with short proximal neck: comparison between standard endograft and open repair

AIM

Comparing the results of the treatment of abdominal aortic aneurysms (AAA) with infra-renal neck length ≤1 cm with open repair (OR) and with endovascular treatment (EVAR) with standard endograft.

METHODS

Patients treated from January 2005 to December 2009 for infra-renal AAA with neck length ≤1 cm, were prospectively included. The choice of treatment was made up on anatomical and clinical criteria. Cases treated with OR (G1) and EVAR (G2) were compared. Primary end-points were: peri-operative mortality/morbidity and re-interventions, renal function worsening at discharge, mortality and re-interventions during follow-up. Secondary end points were: procedure time, need and time of intensive unit care (IUC) hospitalization, need for blood transfusions and hospital days. The comparison between groups was estimated by the Long-rank test.

RESULTS

Eighty-two patients were treated (76 males and 6 females); the mean age was 71.4 years (range 56-86) and the mean AAA diameter was 6.2 cm. Forty-four patients were enrolled in G1 and 38 in G2. The two groups were clinically homogeneous, except for: age (G1<G2: P<0.001), chronic obstructive pulmonary disease (COPD) (G1<G2: P=0.016) and obesity (G1<G2: P=0.045). The mean follow-up was 26 months (range 1-63.6). The overall operative mortality was 3.7%: all deaths (3 cases) occurred in G1 (6.8%) while no deaths occurred in G2 (P=NS). The association of peri-operative morbidity and mortality was higher in G1 (P=0.012). There were 7 peri-operative re-interventions, 4 in G1 (9%) and 3 in G2 (7.8%) (P=NS). There was no statistical difference in renal function worsening at discharge between the two groups. At 36 months overall survival was 84% and the survival of G1 and G2 was respectively 80.5% and 87.4% (P=NS). At 36 months, freedom from re-intervention was 82.6% in G1 and 88.4% in G2 (P=NS). All the secondary end points were significantly better in G2.

CONCLUSION

These results show that EVAR with standard endograft is an effective and reliable option in AAA with neck length ≤1 cm in short and mid-term follow-up. Long-term follow-up results are needed.

The presymptomatic phase of Huntington disease

Huntington disease is a neurodegenerative disorder transmitted as an autosomal dominant trait. It is the first neurological disease for which presymptomatic testing has been available for 20years in France. Follow-up of mutation carriers provided a better understanding of the presymptomatic phase of the disease and will change medical practice. Studying this phase led to the identification of clinical, imaging and plasma markers prior to motor onset, which will allow finding the optimal window for preventive treatment and follow-up of its efficacy.

Pancreatic injury during AAA repair: a comparison between EVAR and open repair

OBJECTIVES

Enzymatic pancreatic injury (EPI) in abdominal aortic aneurysm (AAA) treatment has been scarcely studied in the literature. Aim of this work was to compare perioperative EPI in AAA patients treated by endovascular repair (EVAR) or open repair (OR).

METHODS

Forty AAA patients consecutively treated with either EVAR (GI, 20 pts) or OR (GII, 20 pts) were prospectively evaluated in terms of epidemiology, comorbidities and technical details. Serum levels of amylase, lipase and pancreatic isoamylase were assessed before treatment (T0), before aortic clamping/endograft deployment (T1), 1, 2, and 6 hours after aortic declamping/endograft deployment (T2, T3, T4) and 24, 48, and 72 hours after the procedure (T5, T6, T7). GI and GII were compared by Mann Whitney test with significance set at p < 0.05.

RESULTS

GI patients were significantly older and with higher frequency of preoperative renal insufficiency than GII ones (p = 0.001 and 0.047 respectively). Other characteristics were not significantly different. Pancreatic enzymes values at T0 were within normal parameters in all patients. Total serum amylase was significantly greater at T4 (p = 0.003), T5 (p = 0.010), T6 (p = 0.003), T7 (p = 0.011) and isoamylase at T3 (p = 0.052), T4 (p = 0.037), T5 (p = 0.016) and T6 (p = 0.014) in GII compared with GI. Amylase and isoamylase peak occurred 24 hours after the procedure. Lipase was significantly different in the two groups only in T4 (p = 0.028). No acute pancreatitis occurred in the whole study group.

CONCLUSIONS

EVAR significantly reduces EPI compared with OR in the AAA treatment.

Analysis of the molecular mobility of collagen and elastin in safe, atheromatous and aneurysmal aortas

AIM OF THE STUDY

In this study, we propose to use a thermal technique, Differential Scanning Calorimetry (DSC) to follow the evolution of elastin and collagen in safe and pathological cardiovascular tissues.

PATIENTS AND METHODS

The first part of this study deals with the analysis of the elastin network and associated proteins during ageing (from children to old persons) in aortic walls. The second part is devoted to the characterization of the collagenic phase in aneurysms. In both cases, physical data are correlated with biochemical analyses.

RESULTS AND CONCLUSION

For old persons aortas with atheromatous stades, elastin and associated proteins are found to interpenetrate to form a homogenous phase. Abdominal aortic aneurysms (AAA) are characterized by structural alterations of the aortic wall resulting from the degradation of elastic fibers and an increase of collagen/elastin ratio. Notable modifications are evidenced between collagen from control tissue and collagen from AAA, particularly concerning the thermal denaturation. Biochemical and thermal results are compatible with the increase of new collagen deposition and/or impairment of the collagen phase stability in the extracellular matrix of AAAs.

AnacondaTM: the Italian Registry. Study protocol and preliminary perioperative results

AIM

AnacondaTM is an infrarenal stent-graft for the endovascular treatment (EVAR) of abdominal aortic aneurysms (AAA). The AnacondaTM Italian Registry is an observational multicentre registry that started in Italy on March 2009. The aim of this study is to present the registry protocol and to evaluate the interim perioperative results.

METHODS

Patient data collected covered both retrospective and new cases. The case record forms are divided into preoperative data (population characteristics and clinical data), preoperative morphological data, intraoperative data, perioperative data (30-days from AnacondaTM implant) and follow-up record forms. The inclusion criteria are: AAA with a maximum sac diameter ≥ 5 cm, AAA with rapid expansion, symptomatic AAA or with a contained rupture, aorto-iliac aneurysms, proximal neck length ≥ 15 mm and diameter of the proximal aortic neck between 16 and 31.5 mm. No exclusion criteria were considered regarding aorto-iliac tortuosity, wall calcification or thrombosis and no exclusion criteria were considered regarding the patients age, comorbidities or life expectancy. Seven postoperative follow-up controls (visit and imaging) were required: at 30-days from the AnacondaTM implant, 6 months, 1 year and then annually up to 5 years. The registry is still open to new case enrollment.

RESULTS

The reported results reflect the registry cases as at March 15, 2011. At this date, 787 cases were present in the database: 722 (91.7%) were male and 65 (8.3%) female. The mean patient age was 76.6 years with a range between 50 and 94 years. The ASA class was ≥ 3 in 635 patients (80.6%). The mean aneurysmal sac diameter was 55.73 ± 9.5 mm. The mean proximal aortic neck length was 26.52 ± 12.31 mm. Of the 787 patients treated, 11 cases of immediate surgical conversion were reported (1.3%). The overall 30-day mortality rate was 1.2% (10 cases): but 30-day death occurred in 0.9% of successful endograft implants and in 27.2% of surgical conversions (p<0.001). In fourteen cases (1.7%) an iliac leg thrombosis occurred and a native iliac artery thrombosis occurred in only five cases (0.5%). The 30-day overall occurrence of endoleaks was observed in 95 cases (12%): 5 cases of type I proximal endoleak (0.6%), 89 cases of type II endoleak (11.3%) and 1 case of type III endoleak (0.1%). No cases of endograft dislocation were reported.

CONCLUSION

This is an interim report on the study protocol and on the preliminary early results. Presently there are no definitive conclusions, however the perioperative results show that the AnacondaTM endograft seems to be safe and effective in the treatment of AAA, even in a high risk cohort of patients. Definitive and long-term results are needed.

Spinal cord ischemia after endovascular treatment of infrarenal aortic aneurysm. Case report and literature review

Spinal cord ischemia is a rare but catastrophic complication after endovascular treatment of infrarenal aortic aneurysm: only 14 cases are reported in the literature. A patient with a 6 cm infrarenal aortic aneurysm extending to both common iliac arteries and high surgical risk was submitted to endovascular repair with exclusion of both hypogastric arteries and surgical revascularization of the right hypogastric artery. The patient presented paraplegia, apallesthesia and superficial hyposensitivity immediately after the procedure. A spinal cord drainage was positioned with little improvement of superficial sensitivity. We undertook a systematic review of the literature on this topic.

Ring-stents supported infrarenal aortic endograft fits well in abdominal aortic aneurysms with tortuous anatomy

AIM

Abdominal aortic aneurysms (AAA) with severe angulation of the neck or of the iliac arteries are often unsuitable for endovascular repair with conventional endografts. We evaluated the performance of a ring-stent abdominal endograft (AnacondaTM Vascutek, Terumo, Scotland) in a consecutive series of infrarenal AAA.

METHODS

Preoperative, procedural and follow-up data of patients treated with AnacondaTM endograft between September 2005 and September 2009 were prospectively enrolled. Patients were divided in Group A (proximal neck angle > or =60 degrees or iliac arteries angle > or =90 degrees ) and Group B (all others). Main endpoints were technical and clinical success (primary and assisted) and late outcome in the two groups. Results were compared by Kaplan-Meier life table analysis with log-rank test (Mantel-Cox).

RESULTS

One hundred twenty-seven patients, with a mean age of 73.5+/-6.9 years, have been included in this series. Mean aneurysm size was 56.7+/-10.4 mm. A severe angulation of the proximal aortic neck or/and of the iliac arteries was present in 44 cases (Group A), absent in 83 cases (Group B). The mean follow-up was 18.2+/-16.3 months. Overall primary technical success was achieved in 100% of the patients. At twenty-four months survival, primary and assisted clinical success were 94.2%, 88.2% and 91.3% in Group A and 80.3%, 83.7% and 95.2% in Group B respectively. No significant differences were found between the two groups. The only factor significantly associated with decreased survival was preoperative renal insufficiency. Iliac limb patency 24 months after EVAR in severely and non-severely angulated iliac axis was 96.7% and 98.1% respectively, with no significant difference between the groups. Only one proximal type I endoleak was detected in a patient with severe angulation of proximal aortic neck. No significant correlation between proximal type I endoleak and severe neck angulation was found.

CONCLUSION

Aneurysms with severe neck or iliac arteries angulation can be treated by a ring-stent endograft with results similar to those of AAA with more favourable anatomy.

[Genetic testing in asymptomatic minors: a survey among French geneticists]

Since their introduction, genetic tests have been carefully considered, with special attention to the release of information about the test and test results, the confidentiality of genetic information, the request and its motivation, and the psychological impact of the test. Careful consideration is needed when family members at risk are asymptomatic children or adolescents. Cautious reflection is warranted on whether and under which conditions genetic testing should be performed. Here, we report on the results of a survey conducted in France among 50 geneticists questioned on their opinions and practices concerning presymptomatic testing in three groups of diseases: those for which a medical benefit exists during childhood (e.g., retinoblastoma), diseases with onset during childhood for which there are no immediate medical consequences (e.g., type II/III spinal muscular atrophy), and those with onset during adulthood for which there is no medical benefit during childhood (e.g., Huntington disease). Guidelines are proposed: presymptomatic testing should not be performed in a minor without individual and direct information, all requests for presymptomatic genetic testing concerning a disease with onset in adulthood should be postponed, and all presymptomatic test requests for a minor should be addressed to a multidisciplinary team.

Successful treatment of Cryptococcal meningitis with a combination of liposomal amphotericin B, flucytosine and posaconazole: two case reports

Cryptococcus neoformans CNS infection frequently affects HIV-infected patients and is often lethal, despite antifungal therapy. The most recent treatment guidelines for Cryptococcal meningitis recommend therapy with lyposomal amphotericin B and possible association with flucitosine. However, clinical response rates in HIV-infected patients are not satisfactory, with a persistent high mortality rate and long term therapy is affected by a high risk of major side effects. Posaconazole, the latest broad-spectrum azole, with both in vitro- and in vivo-documented potent activity against C. neoformans, clearly showed no antagonism with amphotericin B, echinocandins or flucytosine and it has both in vitro and in vivo agonistic activity with flucytosine against C. neoformans. We report two cases of successful salvage therapy based on the addition of posaconazole to a standard treatment based on liposomal amphotericin B and Flucytosine. In addition we used posaconazole also in a maintenance therapeutic regimen with no evidence of recurrences in the follow up of these patients. Our report confirms that posaconazole has clinical activity in the CNS against C. neoformans infection. In addition posaconazole showed no antagonism with any other currently available antifungal agent, and was in fact synergistic to some of them (flucytosine); consequently, it seems to be an ideal candidate for antimicrobial combination salvage therapies. Finally posaconazole represents a good alternative to parenteral therapy and an ideal candidate for long-term maintenance therapy due to its competent toxicity profile and oral bioavailability.

The advantages of Anaconda endograft for AAA

AIM

The Anaconda endograft (Vascutek, Terumo, Inchinnan, Scotland) is an infrarenal, trimodular stent-graft with peculiar characteristics in terms of implant, proximal sealing and fixation of the main body and iliac legs. This endograft can be used in infrarenal abdominal aortic aneurysm (AAA) with an aortic neck >or=15 mm in length. The authors evaluated the mid-term outcome of the Anaconda endograft in the treatment of infrarenal AAA also in cases with tortuous anatomy.

METHODS

Between September 2005 and September 2008, 100 patients (94 males, 6 females) with mean age of 73.9+/-5.2 years (range 55-89) were considered eligible for treatment with Anaconda endograft (proximal neck length >or=15 mm). The mean aneurysm size was 55.2+/-3.4mm (range 45-99 mm). An angulation of the aortic neck greater than 60 degrees was present in 19 cases. The iliac arteries were severely angulated >60 degrees in 61 patients. The mean follow-up was 23.2+/-11.0 months (range 1.4-38.6).

RESULTS

Primary technical success was achieved in 100% of the patients. Six patients died during follow-up, none for aneurysm-related causes. Survival rate was 87.9% at 24 months of follow-up. Primary and assisted clinical success were respectively 80.8% and 93.7% at 24 months with a freedom from reintervention of 88.8%. No cases of endograft migration were observed and only one case of type I proximal endoleak was recorded in the mid-term follow-up. The univariate and the multivariate analysis did not show an increased risk in patients with angulated proximal neck or iliac arteries.

CONCLUSIONS

As evidenced in this clinical study, the mid-term outcomes of Anaconda endograft are satisfactory concerning the treatment of AAA with a minimum neck length of 15 mm. This device proved in the mid-term to effectively protect the patient treated from aneurysm rupture. Presence of even severe tortuosity of the proximal neck and of the iliac arteries did not affect outcomes. Considering these results showing the safety of Anaconda endograft, the authors suggest its employment also in cases with difficult anatomy.

Preliminary Results of Anaconda™ Aortic Endografts: A Single Center Study

OBJECTIVE

To evaluate the peri-operative results of Anaconda endograft in the first 49 cases treated in a single centre.

METHODS

The study was carried out prospectively on cases of infrarenal abdominal aortic aneurysm (AAA) treated with Anaconda endograft. The characteristics of the proximal aortic neck and of the iliac access vessels were considered. The following operative results were assessed: the main body oversizing, the need to correct the positioning of the main body, the use of iliac extensions, the use of ballooning, the covering of patent hypogastric arteries, the presence of endoleaks and the need for conversion. Peri-operative (30 days) mortality and morbidity were also considered.

RESULTS

Of the 49 cases treated, 44 were males with a mean age of 73 years (range: 55-89 yrs; SD+/-7 yrs). The mean diameter of the AAA was 56 mm (range 45-91 mm; SD+/-11); 4 cases had common iliac aneurysms with a diameter >3 cm. The mean neck diameter and length were 23 mm (range 19-28 mm; SD+/-3) and 25 mm (range 15-50 mm; SD+/-10) respectively. An aortic neck angle between 40 degrees and 70 degrees was present in 10 cases (20%) (mean 58 degrees; SD+/-15 degrees), and 20 cases (41%) had iliac tortuosity with an angle greater than 60 degrees (mean 85 degrees; SD+/-25 degrees). There were no cases of conversion or intra-operative death. One (2%) peri-operative death occurred, for reasons not related to the endograft. There were two cases of iliac limb thrombosis. CT at one month showed 12 cases (25%) of type II endoleak. There were no cases of type I or type III endoleaks.

CONCLUSIONS

The preliminary data of this series demonstrates that the Anaconda endograft has good peri-operative results in the treatment of infrarenal AAAs with a neck length not less than 15 mm.

Aortic Arch Anomalies are Associated with Increased Risk of Neurological Events in Carotid Stent Procedures

OBJECTIVE

To establish the risk of carotid artery stent (CAS) complications in patients with aortic arch anomalies.

METHODS

In a prospective series of patients submitted to CAS, all cases with arch anomalies were compared with cases with normal arch anatomy (type I, II and III) in order to assess the impact of anatomic characteristics on technical and clinical outcome. Outcome was evaluated in term of neurological complications and technical success.

RESULTS

Of 214 consecutive patients undergoing CAS, 189 (88.3%) had normal arch anatomy and 25 (11.7%) arch anomalies. The arch abnormalities included common origin of brachiocephalic trunk and left common carotid artery in 22 cases (10.2%), separate origin of right subclavian and common carotid in 2 cases (0.9%) and left common carotid agenesis with separate arch origin of internal and external carotid in 1 case (0.5%). The two groups were not different in term of epidemiology and preoperative clinical and morphological characteristics. Technical failure occurred overall in 26 cases (12%) and neurological complication in 14 cases (6.5%). All symptoms were temporary. Technical failure was higher in the arch anomaly group; however the difference did not reach statistical significance (89.6% vs 76.4%, P=0.1). Neurological complications occurred more frequently in the arch anomaly group (20% vs 5.3%, P=0.039). Type of arch was the only variable independently associated with neurological complications (OR=2.01, p=0.026).

CONCLUSION

Aortic arch anomalies are not infrequent and are associated with increased risk of neurological complications. The indication for CAS should be carefully evaluated in these cases.

Carotid Stent Failure: Results of Surgical Rescue

AIM

Little data is available on surgical "rescue" of failed carotid stents (CAS). We have analyzed a series of CAS failures treated by conventional open surgery.

REPORT

Five patients underwent surgery after CAS failure, either electively (4) or as an emergency (1). Elective surgical "rescue" was for stent restenosis (2 cases) or stent misplacement (2 cases). Emergency surgery was performed for entrapment of the protection system in the stent. Surgical rescue was accomplished by perimedial endarterectomy and "en bloc" plaque and stent extraction in 3 cases, and by vein bypass in 2 cases, with no neurological complications.

CONCLUSION

Surgical rescue of failed CAS is effective.

Endovascular and Hybrid Treatment of Recurrent Thoracoabdominal Aneurysms in an HIV-positive Patient

INTRODUCTION

We report a case of staged endovascular and hybrid treatment of recurrent thoracoabdominal aneurysms (TAAA) in a 55-year-old HIV-positive man.

REPORT

A patient, who had previously been surgically treated for a type III TAAA, presented with recurrent aneurysms. The patient was treated by a combination of endovascular and open surgery. Neither visceral nor spinal ischemia were observed.

CONCLUSION

The hybrid treatment of recurrent TAAA could offer lower mortality and morbidity. Patients with HIV/AIDS treated for aortic aneurysms require close follow-up.