Study Protocol of a Prospective, Monocentric, Single-Arm Study Investigating the Correlation of Endograft Properties with Aortic Stiffness in Abdominal Aortic Aneurysm Patients Subjected to Endovascular Aortic Repair

The number of endovascular aortic repairs (EVARs) has surpassed the number of open surgical repairs of abdominal aortic aneurysms (AAAs) worldwide. The available commercial endoprostheses are composed of materials that are stiffer than the native aortic wall. As a consequence, the implantation of stent-graft endoprostheses during EVAR increases aortic rigidity and thus aortic stiffness, resulting in a decrease in abdominal aorta compliance. EVAR has been found to have a possibly harmful effect not only on heart functions but also on other vascular beds, including kidney function, due to the decrease in aortic compliance that it causes. Aortic stiffness is measured by various hemodynamic indices like the pulse wave velocity (PWV), the central aortic pressure (CAP), and the augmentation index (AIx). In the literature, there are increasing numbers of studies investigating the properties of endografts, which are strongly related to increases in aortic stiffness. However, there is a lack of data on whether there is a correlation between the length of various endografts implanted during EVAR and the increase in the PWV, CAP, and AIx postoperatively compared to the preoperative values. The aim of this prospective, observational, monocentric, single-arm study is to investigate the correlation between endograft length and the postoperative increase in the PWV, CAP, and AIx in patients subjected to EVAR. Additionally, this study intends to identify other endograft properties related to increases in the PWV, CAP, and AIx. Other endpoints to be studied are the existence of immediate postoperative myocardial and kidney injury after EVAR. The prediction of cardiovascular events caused by endograft-related increased aortic stiffness could contribute to the improvement of various endograft properties so that the impact of endografts on the native aortic wall can be minimized.

One-Year Outcomes of CGuard Double Mesh Stent in Carotid Artery Disease: A Systematic Review and Meta-Analysis

Background: Prospective single and multicenter studies have shown improved outcomes of patients who underwent carotid artery stenting with the novel CGuard dual-layer mesh stent at 1 year. Objectives: The aim of this study is to conduct a systematic review and meta-analysis of all published studies to assess 1-year efficacy and outcomes of CGuard in patients with carotid stenting. Methods: A systematic search was performed. All studies enrolling at least 20 patients were included in our analysis. The primary endpoints were death (all-cause, cardiovascular and ipsilateral stroke-related death) and stroke rate at 1 year. The secondary endpoint was in-stent restenosis at 1 year. Results: The final analysis included 1709 patients. The one-year all-cause mortality rate was 2.97% (39/1699, 95% CI: 1.26-6.86%, I2 = 67%, t2 = 0.3442, p < 0.01), cardiovascular-related death was 0.92% (10/1616, 95% CI: 0.35-2.39%, I2 = 34%, t2 = 0.2302, p = 0.18), and ipsilateral stroke-related death was 0.3% (1/1649, 95% CI: 0.1-0.87%, I2 = 0%, t2 = 0, p = 0.69). The one-year ipsilateral stroke rate was 1.21% (16/1649, 95% CI: 0.58-2.5%, I2 = 28%, t2 = 0.1433, p = 0.23), transient ischemic attacks (TIAs) rate was 1.78% (19/1149, 95% CI: 1.11-2.84%, I2 = 0%, t2 = 0, p = 0.69), and total composite 1-year stroke/TIA rate was 2.97% (32/1149, 95% CI: 1.84-4.77%, I2 = 0%, t2 = 0, p = 0.41). The in-stent restenosis rate at 1 year was 1.06% (13/1653, 95% CI: 0.48-2.34%, I2 = 28%, t2 = 0.2308, p = 0.22). Conclusions: This meta-analysis shows that CAS with CGuard is safe with minimal neurological adverse events and in-stent restenosis rate at 1 year.

12-Month Outcomes of Carotid Artery Stenting With CGuard MicroNET-Covered Stent: A Single-Center Study in 113 Patients

Dual layer mesh stents constitute a novel treatment option for patients who undergo carotid artery stenting (CAS). The aim of this prospective study is to report 12 month outcomes of patients who underwent CAS with CGuard (Inspire MD, Tel Aviv, Israel) microNET self-expanding stent with embolic protection system in a tertiary center from October 2018 to March 2022. Primary endpoints included in-stent restenosis >70% verified by ultrasound (DUS), ipsilateral transient ischemic attack (TIA), and stroke at 12 months. Secondary endpoints included cardiovascular-related mortality (stroke, myocardial infarction, heart failure) and all-cause mortality during follow-up. One hundred thirteen patients were included in the study (male 72.5%), symptomatic 47.8%. Median follow-up was 25 months (2-48). By 12 months, there was one in-stent occlusion that manifested as stroke (1/113, 0.8%) but no other forms of in-stent restenosis. Two patients experienced contralateral TIA (1.7%). CVRM was 3.5% (4 MI) and all-cause mortality was 6% at follow-up. This prospective study shows that CAS with CGuard MicroNET-covered stent is safe with minimal neurological adverse events at 12 months follow-up. Larger, and longer-term studies are necessary to define CGuard long-term safety and protection against carotid-related stroke.

Endograft Anaconda in endovascular aneurysm repair: a systematic review of literature and meta-analysis

OBJECTIVES

To conduct a systematic review of the literature and meta-analysis of studies reporting patients with infrarenal AAA subjected to EVAR with the Anaconda endograft.

METHODS

We performed a systematic review of multiple electronic databases for studies including patients with infrarenal AAA who were subjected to elective EVAR with Anaconda endograft exclusively. We conducted a proportional meta-analysis cumulating results of the included studies. The endpoints were 1^st month overall mortality, 1^st and 2^nd year survival after EVAR, AAA related deaths, incidence of endoleaks, endograft migration, endograft occlusion, open conversion, primary and secondary technical success. Mean value for each separate studied factor was calculated and the respective percentage/incidence was extracted, so that it can be compared to endograft outcome studies in the literature. We assessed methodologic quality of studies by using the Briggs Institute critical appraisal tool.

RESULTS

Seven observational studies were found including 954 patients (males 91.9%, mean age 73.38±6.97 years). Mean transverse diameter of AAAs was 56.83±9.97mm. Mean proximal aortic neck diameter and length were 23.06±3.33mm and 24.14±12.16mm respectively. Increased aortic neck calcification and aortic neck thrombus were present in 12.5% of patients. 30-day overall mortality post-EVAR was 1.3%, 1- and 2-year survival rates were 95.9% and 91.4% respectively. Mean follow up period in the studies was 46.59±15.5 months. AAA related mortality was 1.3%. Primary technical success was 97.9% and secondary 99.3%. Open conversion was required in 3.4% of all patients (0.6% during the primary operation). The most common endoleak was type II reported in 17.4% of all patients. Early type Ia endoleak was reported in 1.5% of patients, late type Ia in 1.7%. Overall, two endoleaks type III and one type IV were reported. Endograft migration occurred in 1.7% of patients. Main body and/or one/both iliac legs thrombotic occlusion was found totally on 7.6% of patients (5 main body occlusions and 64 iliac leg occlusions).

CONCLUSIONS

The use of Anaconda endograft in electively treated patients with infrarenal AAAs presented good results with high technical success and low postoperative and mid-term complications except for increased incidence of stent-graft thrombosis, which seems to be the "Achilles heel" of the device.

The effectiveness and safety of direct oral anticoagulants compared to conventional pharmacologic thromboprophylaxis in hip fracture patients: A systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Direct oral anticoagulants (DOACs) are recommended as a possible pharmacologic venous thromboembolism (VTE) prophylaxis in patients undergoing total hip arthroplasty (THA) and total knee arthroplasty (TKA). However, current guidelines did not introduce recommendations for administration of DOACs as an option for pharmacologic VTE prophylaxis in patients undergoing hip fracture surgery (HFS). The purpose of this study is to compare the effectiveness and safety of DOACs administered for pharmacologic VTE prophylaxis in patients undergoing HFS to conventional pharmacologic VTE prophylaxis, as well as mortality between these thromboprophylaxis medications.

METHODS

We performed a systematic review of multiple electronic databases for randomized controlled trials (RCTs) including patients who were subjected to HFS and prescribed either DOACs as pharmacologic VTE prophylaxis or a conventional VTE prophylaxis drug. We conducted a meta-analysis comparing effectiveness, safety and mortality of these agents between the patient groups studied. Three endpoints were studied. The first one regarding the effectiveness of the agents included clinical manifestations of VTE. The second one regarding the safety of the agents included clinical presentation of bleeding. The latter endpoint studied was mortality of patient groups studied. We generated forest plots to depict the relative risk of the above clinical manifestations between the two studied patient groups and to investigate if there is statistical significance for each patient group to present any of these clinical manifestations. Additionally, we calculated the inconsistency (I²) statistic and assessed the risk of bias of RCTs included in our meta-analysis by using the modified Cochrane collaboration tool.

RESULTS

We selected 2 RCTs in this review including 279 patients totally. Patients of control groups in both eligible studies were administered enoxaparin, which is a low molecular weight heparin (LMWH). The meta-analysis found no statistically significant difference between patients prescribed DOACs and patients prescribed LMWH for VTE (95% CI 0.19 to 1.13, RR=0.46, p=0.09), deep vein thrombosis (DVT) (95% CI 0.21 to 1.32, RR=0.53, p=0.17) and pulmonary embolism (PE) (95% CI 0.03 to 3.12, RR=0.33, p=0.33), major bleeding events (95% CI 0.57 to 1.78, RR=1.01, p=0.97), minor bleeding events (95% CI 0.72 to 1.64, RR=1.09, p=0.69), all bleeding events (95% CI 0.79 to 1.38, RR=1.05, p=0.74) and mortality (95% CI 0.01 to 8.0, RR=0.33, p=0.5). The major risk of bias of the selected RCTs was the fact that either the researchers or the patients could have knowledge whether the latter were administered DOACs or LMWHs.

DISCUSSION

DOACs are not inferior compared to LMWHs regarding their effectiveness, safety and mortality in patients subjected to HFS. Further studies with larger patient samples should be conducted in the future, so that safer results and conclusions could be reached.

Polymer Free Amphilimus Drug Eluting Stent for Infrapopliteal Arterial Disease in Patients with Critical Limb Ischemia: A New Device in the Armamentarium

Background and Objectives: Endovascular technologies have significantly improved the outcome of patients with critical limb ischemia (CLI). Drug eluting stents (DES) have documented their efficacy against percutaneous transluminal angioplasty (PTA) and bare metal stents (BMS) in infrapopliteal arterial occlusive disease. However, late in-stent neoatherosclerosis may lead to vascular lumen loss and eventually thrombosis. Polymer free DES constitute a new technology aiming to improve long term patency which their action is still under investigation. The purpose of this study is to report the mechanism of action and to provide a literature review of a novel polymer free amphilimus eluting stent (Cre8, Alvimedica, Instabul, Turkey) in infrapopliteal arterial disease. Methods: Publications listed in electronic databases, European Union Drug Regulating Authorities Clinical Trials Database, as well as scientific programmes of recent interventional vascular conferences were searched. Three studies were included. We analyzed primary and secondary patency, major amputation rate, freedom from CD-TLR, and mortality. Results: Cre8 was implanted in 79 patients with CLI. Most of the patients (n = 65) were Rutherford class 5-6 (82.3%), and diabetes mellitus (DM) was present in 66 patients (83.5%). Mean primary patency was 82.5% at 12 months. Mean lesion stented length was 20 mm and 35 mm in two studies. Mean limb salvage was 91.3% at 12 months. Freedom from CD-TLR was reported in two out of the three studies and was 96% and 83.8%. Mortality was 15% and 23.8% in the same studies, whilst it was not reported in one study. Conclusion: Stenting of infrapopliteal arteries with Cre8 is safe and feasible in patients with CLI and diabetes. All studies have shown very good primary patency and freedom from CD-TLR at 12 and 24 months. Larger observational prospective studies and randomized trials are necessary to establish long term effectiveness and clinical outcomes using the non-polymer Cre8 DES.

Long-Term Effects of Acute Kidney Injury Following Endovascular Femoropopliteal Intervention: Insights From a Multicenter Trial

PURPOSE

To examine the association between acute kidney injury (AKI) severity and duration with cardiovascular mortality, following endovascular treatment of femoropopliteal disease, and whether it is AKI in itself that confers an increased risk of cardiovascular mortality.

METHODS

A retrospective analysis of prospectively collected data obtained between 2014 and 2019 from 3 vascular centers. Renal function was followed up for a minimum of 90 days. Electronic records were queried to establish a cause of death, where applicable. Patients were excluded if unable to provide written informed consent or if presenting with acute limb ischemia. Primary outcomes were the hazard ratios for cardiovascular death (AKI patients vs no AKI; no AKI vs stage 1 AKI vs stage 3 AKI; and no AKI vs transient AKI vs established AKI). Propensity score-matched analysis was used to establish whether developing AKI, in patients with similar demographics and procedural characteristics, is associated with a higher risk of cardiovascular death.

RESULTS

Overall 239 patients developed AKI, and this was associated with an increased risk of cardiovascular mortality (hazard risk [HR]: 4.3, 95% confidence intervals [CIs]: 2.1-6.8, pairwise comparison p value=0.006]. This was dependent on the severity of the AKI stage (HR 5.4, 95% CI: 2.4-7.3, pairwise comparison p value=0.01) and duration (HR 4.2, 95% CI: 2.3-6.2, pairwise comparison p value=0.04). The propensity score-matched analysis showed that even when patients are matched for comorbidity and procedural characteristics, AKI confers an increased risk of mortality (p=0.04).

CONCLUSIONS

Acute kidney injury is common after femoropopliteal endovascular therapy. It confers an increased risk of long-term cardiovascular mortality, which is still present when renal decline is transient, and highest for patients with established decline in renal function.

CLINICAL IMPACT

This is the first study in the setting of peripheral arterial disease to show that acute kidney injury has an adverse effect on cardiovascular mortality, in the long-term, that is dependent on its severity, and present even when the AKI is transient. We have also shown that this difference in cardiovascular mortality becomes more pronounced from the medium-term, and thus closer follow-up of these patients is required.

One-year outcomes following primary stenting of infrapopliteal steno-occlusive arterial disease using a non-polymer sirolimus-eluting stent: Results from a prospective single-centre cohort study

Background

Clinical outcomes using new generation drug-eluting stents designed specifically for infrapopliteal disease are not widely available, especially in comparison to paclitaxel-based therapies. This series reports 1-year outcomes in patients with diabetes and chronic limb threatening ischaemia (CLTI) undergoing angioplasty, with a sirolimus-eluting tibial stent (Cre8, Alvimedica, Turkey), evaluating the feasibility, safety, and efficacy of this new device. Outcomes were compared to matched patients undergoing infrapopliteal angioplasty using a paclitaxel-coated balloon (DCB).

Patients and Methods

Patients with diabetes and CLTI requiring infrapopliteal intervention were recruited prospectively to undergo angioplasty and primary stenting using the Cre8 sirolimus-eluting stent between January 2018 and October 2020 at a single high-volume vascular centre; outcomes were compared to a group of patients with diabetes and CLTI who had undergone infrapopliteal angioplasty using a DCB. All patients were followed up for at least 12 months using a uniform protocol with duplex ultrasound and examination. The primary outcome measure was target lesion patency (<50% restenosis). Clinically driven target lesion revascularisation (CD-TLR), amputations, Rutherford stage, and mortality were also recorded.

Results

A total of 54 patients (61 target lesions; median age: 69 years, 74% male) were included [27 with the Cre8 device (main group) vs. 27 with a DCB (historical controls)]. Primary patency at 12 months was 81% in the Cre8 group vs. 71% in the control group (p = 0.498). Overall, four (15%) patients in the Cre8 group vs. three (11%) patients in the control group underwent a major amputation within 12 months (p = 1.0). CD-TLR (all endovascular) did not differ between groups at 12 months (4% Cre8 vs. 10% control group, p = 0.599). Rutherford stage improvement at 12 months was superior for the Cre8 group (52% vs. 15% improved by at least one stage, p = 0.039). One-year mortality was 15% in the Cre8 group vs. 22% in the control group, p = 0.726.

Conclusions

Primary stenting with the Cre8 stent is feasible and safe in diabetic patients and CLTI. When compared to patients undergoing angioplasty with a DCB, there were no significant differences regarding primary patency, CD-TLR, major amputations, and mortality at 12 months. Those treated with a Cre8 stent were more likely to have an improvement in their Rutherford stage.

Obstructive Jaundice Caused by a Large Intact Abdominal Aortic Aneurysm. Case Report and Literature Review

BACKGROUND

Obstructive jaundice caused by abdominal aortic aneurysm (AAA) is an extremely rare clinical presentation. We present an 85-year-old male with a large intact AAA causing obstructive jaundice and review the relevant literature.

METHODS AND RESULTS

The patient was referred to our hospital with jaundice and a palpable pulsatile abdominal mass. Computerized tomography (CT) angiogram and magnetic resonance cholangiopancreatography (MRCP) revealed an infrarenal AAA with maximal diameter of 8.5 cm compressing the pancreatic head and common bile duct, causing obstructive jaundice with elevated levels of total, and direct bilirubin. The patient was subjected to endovascular aneurysm repair (EVAR). Blood bilirubin gradually decreased to normal levels. No complications were reported during the immediate postoperative and at 3-month follow up period. Literature review suggests that our case is one of the largest intact AAAs which have been reported to cause biliary obstruction.

CONCLUSIONS

AAAs causing secondary obstructive jaundice is an uncommon clinical presentation requiring high clinical suspicion during differential diagnosis, so that patients can receive proper and early diagnosis and treatment.

Position Paper on Young Vascular Surgeons Training of the Mediterranean Federation for the Advancing of Vascular Surgery (MeFAVS): State of the Art and Perspectives

The Mediterranean Federation for the Advancing of Vascular Surgery (MeFAVS) was founded in 2018, with the aim to promote cooperation among vascular professionals within Mediterranean countries. Due to its prominent social and economic impact on national health systems, diabetic peripheral artery was selected as the very first topic to be investigated by the federation. In this second paper, different experiences from delegates of participating countries were shared to define common strategies to harmonize, standardize, and optimize education and training in the Vascular Surgery specialty.

Acute kidney injury following endovascular intervention for peripheral artery disease

BACKGROUND

The incidence of, and risk factors for, acute kidney injury (AKI) after endovascular intervention for peripheral artery disease (PAD) remain unknown. The aim of this study was to assess the proportion of patients who develop AKI and explore the risk factors.

METHODS

Prospectively collected data on patients undergoing femoropopliteal endovascular intervention for symptomatic PAD across three vascular centres were analysed. The proportion of patients developing AKI (according to the Kidney Disease Improving Global Outcomes definition) within 48 h, and the proportion developing the composite Major Adverse Kidney Events (MAKE) endpoints (death, dialysis, drop in estimated glomerular filtration rate at least 25 per cent) at 30 days (MAKE30) and remains 90 days (MAKE90) were calculated. Multivariable regression analysis was used to assess predictors of AKI, and the association between AKI and death.

RESULTS

Some 2041 patients were included in the analysis. AKI developed in 239 patients (11.7 per cent), with 47 (2.3 per cent) requiring dialysis within 30 days, and 18 (0.9 per cent) requiring ongoing dialysis. The MAKE30 and MAKE90 composite endpoints were reached in 358 (17.5 per cent) and 449 (22.0 per cent) patients respectively. Risk factors for AKI were age, sex, congestive heart failure, chronic limb-threatening ischaemia, emergency procedure, and pre-existing chronic kidney disease. AKI, dementia, congestive heart failure, and major amputation were risk factors for medium-term mortality.

CONCLUSION

AKI is a common complication after intervention for PAD and is associated with medium-term mortality.

Thirty-Day Results of the Novel CGuard-Covered Stent in Patients Undergoing Carotid Artery Stenting

OBJECTIVE

The aim of this study was to provide early-term evaluation, safety, and efficacy of the novel CGuard (Inspire MD, Tel Aviv, Israel) micromesh self-expanding stent with embolic protection system (EPS) during carotid artery stenting (CAS) procedure.

MATERIALS AND METHODS

All patients who underwent CAS with CGuard carotid stent system from January 2018 to September 2020 in a tertiary center were prospectively evaluated. Primary endpoints included technical success and perioperative neurological events (0-48 hours). Secondary endpoint was the rate of neurologic, cardiac events, and death (major adverse event or MAE) at 30 days. Patency of CGuard, peak systolic velocity (PSV), and end diastolic velocity (EDV) were evaluated at 30 days with duplex ultrasound.

RESULTS

A total of 103 patients underwent CAS procedure. Forty patients were symptomatic, and 63 patients were asymptomatic with stenosis greater than 70%. Technical success was 100%. Local anesthesia was applied in 94 patients (93%). Embolic protection devices were used in 6 patients (5.8%). Access site complications were 1.9%. Mean internal carotid artery stenosis diameter reduced from 79.47% to 14.68%. Two patients had transient ischemic attack (1.9%) and 1 patient experienced a cerebral hyperperfusion syndrome (CHS) perioperatively. External carotid artery (ECA) occlusion occurred in 1.9%. Four patients experienced jaw claudication (3.8%) postoperatively. Mean time of operation was 41 minutes. Mean duration of hospitalization was 3.1 days. The 30-day rate of MAE was 0%. CGuard patency was 100%, mean internal carotid PSV was reduced from 251.57 to 77.29 cm/s, and mean internal carotid EDV was reduced from 154.62 to 24.63 cm/s at 30 days.

CONCLUSION

Our study shows that CGuard stent with EPS is an effective and safe device for treatment of carotid artery stenosis with acceptable low perioperative neurologic events, even with low embolic protection device usage. Larger multicenter and randomized studies are necessary to confirm its long-term efficacy.

Outcomes of Endovascular Aneurysm Repair Using the Anaconda Stent-Graft

Purpose: To report outcomes of elective endovascular aneurysm repair (EVAR) using the Anaconda stent-graft in a tertiary vascular center. Materials and Methods: A retrospective study was conducted of 271 patients (mean age 71.5 years; 260 men) who underwent elective EVAR for abdominal aortic aneurysm using the Anaconda stent-graft from January 2006 to January 2017. Median aneurysm diameter was 58 mm (range 50-90). All patients were anatomically suitable for EVAR according to the 2003 version of the instructions for use. Follow-up included computed tomography angiography at 1, 6, and 12 months and yearly thereafter for the first 4 years and then every 2 years. Primary outcomes included technical success and 30-day aneurysm-related mortality and complications; secondary outcomes were overall and aneurysm-related mortality and aneurysm-related morbidity in follow-up. Results: The Anaconda stent-graft was implanted successfully in all patients. Primary and secondary technical success rates were 99.6% and 100%, respectively. Three patients (1.1%) died within 30 days of causes unrelated to the aneurysm, while 15 patients (5.5%) suffered perioperative complications. Median follow-up was 72 months (range 14-141). The overall type I endoleak rate was 4.7% (11 proximal, 2 distal). Late aneurysm-related complications were observed in 48 patients (17.3%); aneurysm-related mortality was 1.4% (n=4). Non-aneurysm-related mortality was 21.0% (n=57). Freedom from reintervention was 95.2% at 1 year, 98% at 2 years, and 90% at 6 years. There was no significant difference in the overall limb graft occlusion rate between the second- and third-generation devices. Conclusion: Results in our cohort study demonstrate that the Anaconda stent-graft has satisfactory early and late results with low aneurysm-related mortality.

Hybrid Repair of Distal Aortic Arch Dissection Aneurysm With Dissected Kommerell Diverticulum

Aberrant right subclavian artery (ARSA) with associated Kommerell diverticulum (KD) is a rare congenital aortic arch anomaly. Patients with KD have a high risk of rupture, dissection, compression of adjacent structures, as well as distal embolization symptoms. Several treatment options have been proposed (surgical, hybrid, endovascular), however, a consensus regarding optimal surgical management has not been established yet. We present a successful single-stage hybrid repair of distal aortic arch dissection aneurysm with dissecting KD and ARSA with debranching of innominate and left common carotid artery, bilateral carotid-subclavian bypass, and stent grafting.

Inferior gluteal artery surgical access for embolization of large internal iliac artery aneurysm in a hostile abdomen

Introduction

Internal iliac artery aneurysms (IIAA) are a rare entity compared with all aortoiliac aneurysms. Continuous expansion due to retrograde flow from runoff vessels can lead to rupture with devastating results. Exclusion of the aneurysm represents a challenging procedure especially if the access is limited and the patient has a history of reoperations in the pelvic region.

Case

A 78-year-old man with a history of endovascular aortic repair, coverage of internal iliac arteries and right hemicolectomy for adenocarcinoma of ascending colon presented with a rapidly expanding right IIAA (8.8 cm) due to type II endoleak. He successfully treated with coil embolization through inferior gluteal artery surgical access.

Conclusion

Inferior gluteal artery surgical access for embolization of internal iliac aneurysms in patients with hostile abdomen or in cases where antegrade route has already been excluded, is a feasible technique.

Prognostic Factors in Patients Treated with Drug-Coated Balloon Angioplasty for Symptomatic Peripheral Artery Disease

Purpose

Aim of this study is to report real-life experience on the treatment of peripheral artery disease (PAD) with a specific drug-coated balloon (DCB), and to evaluate potential prognostic factors for outcomes.

Materials and Methods

This is a retrospective study reporting outcomes in patients with PAD who were treated with the Lutonix DCB during a four-year period. Major outcomes included: all-cause mortality, amputation, clinical improvement, wound healing and target lesion revascularization (TLR). Mean follow-up was 24.2±2.3 months.

Results

Overall, 149 patients (mean age: 68.6±8.3 years; 113 males) were treated, either for intermittent claudication (IC) (n=86) or critical limb ischemia (CLI) (n=63). More than half the target lesions (n=206 in total) were located in the superficial femoral artery and 18.0% were below-the-knee lesions. CLI patients presented more frequently with infrapopliteal (P=0.002) or multilevel disease (P=0.0004). Overall, all-cause mortality during follow-up was 10.7%, amputation-free survival was 81.2% and TLR-free survival was 96.6%. CLI patients showed higher all-cause mortality (P=0.007) and total amputation (P=0.0001) rates as well as lower clinical improvement (P=0.0002), compared to IC patients. Coronary artery disease (CAD), gangrene and infrapopliteal disease were found to be predictors for death whereas CLI and gangrene were found to be predictors for amputation, during follow-up.

Conclusion

PAD treatment with Lutonix DCBs seems to be an efficient and safe endovascular strategy yielding promising results. However, CAD, gangrene, CLI and infrapopliteal lesions were found to be independent predictors for adverse outcomes. Larger series are needed to identify additional prognostic factors.

Endovascular Stent-graft Repair of Combined Renal Artery Aneurysm and Arteriovenous Fistula

Renal artery aneurysm with concomitant presence of arteriovenous fistula is an extremely rare entity. Few reports have been described in the literature. Nowadays, endovascular repair with covered stents or transarterial embolization with coils or glue has become the first line of treatment. We present the successful repair of a distal renal artery aneurysm combined with arteriovenous fistula with stent graft.

Quantitative Evaluation of the Systemic Effects of Transposed Basilic Vein to Brachial Artery Arteriovenous Fistula: A Prospective Study

Background

The transposed basilic vein to brachial artery arteriovenous fistula (BBAVF) constitutes an alternative autogenous vascular access (VA) site for chronic hemodialysis (HD); however, the hemodynamic effects of this procedure have not been adequately studied. The purpose of this study is to evaluate the effects of BBAVF on systemic arterial pressure, cardiac function, and upper limb ischemia (ischemic steal syndrome) utilizing reproducible quantitative methods.

Methods

Ten consecutive patients (eight males; mean age: 65.10 ± 2.87 yrs) scheduled to undergo a brachial-basilic vein transposition were included, excluding patients with cardiac failure. Blood flow volume at the level of the AVF, systemic arterial pressure (SAP), cardiac output (CO) and digital brachial index (DBI) were measured intra-operatively, before and after the creation of the BBAVF, and post-operatively on the 30th post-operative day and on the 3rd post-operative month.

Results

SAP and DBI at 30 days and 3 months post-operatively were significantly lower compared to baseline. CO at 30 days and 3 months post-operatively was significantly higher compared to baseline; however, none of the patients developed cardiac failure. DBI remained ≥0.6 at 3 months, except in one case (0.59). Blood flow volume at the level of the AVF was positively correlated with CO levels on the 30th post-operative day. Mean clinical follow-up was 12 months (range: 4–15 months). In two cases (20%) the AVF was thrombosed (4th and 10th post-operative month).

Conclusion

This prospective quantitative study proves that the BBAVF does impact significantly upon SAP, CO, and DBI; however, it is safe in terms of high-output cardiac failure and ischemic steal syndrome. The authors state that they do not have any commercial, proprietary, or financial interest in any products or companies described in this article.

Endovascular Repair of Blunt Thoracic Aortic Trauma: Is Postimplant Hypertension an Incidental Finding?

BACKGROUND

Blunt thoracic aortic injury (BTAI) is the second most common cause of death in trauma patients. Nowadays, thoracic endovascular aortic repair (TEVAR) has become the treatment of choice because of lower rates of mortality, paraplegia, and stroke. However, concerns have been raised whether graft implantation is related to the development of hypertension in the postoperative period. The aim of this study was to report short- and long-term outcomes of patients undergoing TEVAR for BTAIs at a tertiary hospital and to investigate postimplant hypertension.

METHODS

Between January 2005 and January 2016, 23 patients with blunt thoracic aortic trauma underwent TEVAR. Median age was 44 years (range, 18-73). Among them, 14 (60.9%) patients were diagnosed with aortic rupture, whereas 9 (39.1%) with pseudoaneurysm. Α single thoracic stent graft was deployed in 21 patients, and the rest 2 patients received 2 stent grafts.

RESULTS

Complete exclusion of the injury was feasible in all subjects (100% primary success). The left subclavian artery (SCA) was intentionally covered in 6 patients (26%). Intraoperative complications included one nonfatal stroke managed conservatively and one external iliac artery rupture treated with iliofemoral bypass. One patient (4.3%) died on the first postoperative day in the intensive care unit (ICU) because of hemorrhagic shock. The overall 30-day mortality and morbidity were 4.3% and 8.7%, respectively. New-onset postimplantation arterial hypertension was observed in 8 (34.8%) previously nonhypertensive patients. Younger age (P = 0.027) and SCA coverage (P = 0.01) were identified as potential risk factors for the development of postimplant hypertension, whereas the presence of concomitant injuries (P = 0.3) and intraoperative complications (P = 0.1) were not. After a median follow-up of 100 months (range, 18-120), 6 of them still remain on antihypertensive therapy, whereas the other 2 did not require permanent treatment.

CONCLUSIONS

TEVAR is a safe approach in the treatment of BTAI associated with low short- and long-term morbidity and mortality rates. Lower age and SCA coverage may contribute to the development of postimplant hypertension. Further larger cohort studies are warranted to elucidate the underlying mechanisms of postimplant hypertension.

Open Repair of a 12-cm Posttraumatic Aneurysm of Right Subclavian Artery

Purpose

To present a rare case of a patient with a 12-cm posttraumatic right subclavian artery aneurysm successfully treated with aneurysmectomy and innominate-axillary bypass.

Case report

A 54-year-old man presented to the emergency department due to progressive dyspnea and hoarseness of voice. His medical record was unremarkable except that he had right-sided pneumothorax and multiple rib fractures from a car accident 16 years ago. A chest X-ray showed a mass in the upper lobe of the right lung, and the patient was hospitalized for further investigation. A computed tomography (CT) with intravenous contrast of the thorax was performed, which depicted a giant aneurysm of the right subclavian artery. Vascular and cardiothoracic surgeons were consulted immediately, and the operation was scheduled. Aneurysmectomy and innominate-axillary bypass were performed. The patient had an uncomplicated progress and was discharged on 5 days followed by a single antiplatelet therapy and symptom-free.

Conclusion

Posttraumatic subclavian artery aneurysm is a rare entity. Imaging of the thorax is essential for the diagnosis and surgical preparation of the patient. Open repair remains the gold standard therapy for subclavian artery aneurysm despite the improvements in endovascular surgery in such huge aneurysms.

Active Proximal Sealing in the Endovascular Repair of Abdominal Aortic Aneurysms

Purpose: To investigate the performance of a new device that uses the STRATA polytetrafluoroethylene graft material and a mechanism that provides active proximal sealing in order to prevent type Ia endoleak during endovascular aneurysm repair (EVAR). Methods: Between April 2013 and July 2014, 21 consecutive patients (all men; median age 71 years, range 60–84 years) with abdominal aortic aneurysm (median diameter 5.9 cm, range 4.9–7.8 cm) and suitable anatomy were offered elective EVAR using the AFX endograft. These patients had an irregular, conical, tapered, or bulging proximal neck, for which this specific device was considered appropriate. Aneurysm exclusion and incidence of type Ia endoleak were the primary outcomes; secondary outcomes included mortality, morbidity, migration, and other graft-related complications. Results: Primary technical success was 90%; 2 intraoperative type Ia endoleaks due to low endograft deployment were treated with additional proximal cuffs. During a median follow-up of 10 months (range 2–15 months), no type I endoleak was observed. One type II endoleak was encountered, with no associated sac enlargement. There was no stent-graft migration or any other device-related complication. One patient had a nonfatal myocardial infarction and another developed renal failure requiring transient dialysis. No deaths occurred. Conclusion: In this early experience, this newly available device appears to be safe and efficient in providing seal along irregularly shaped necks over the short term.

Rupture After Endovascular Abdominal Aortic Aneurysm Repair

A total of 22 patients with ruptured abdominal aortic aneurysms (rAAAs) after previous endovascular aortic repair (EVAR; rAAAevar) were presented to 7 referral hospitals in Greece, between January 2006 and April 2012. Type Ia endoleak and endograft migration were identified in 72.7% and 50%, respectively. Compliance to follow-up protocol prior to rupture was 31.8%. In-hospital mortality was 36.4% (9.1% for those treated with secondary EVAR and 63.6% for those treated with open surgical repair, P = .02). An increase in the proportion of patients with rAAAevar among the total number of patients with rAAAs from 1.3% in 2007 to 18.2% in 2012 ( P for trend = .04) was recorded, corresponding to an annual increase of 2.8% (b = 2.84, P = .04). Rupture after EVAR seemed to be a clinical entity encountered with increasing frequency over the past years. Type I endoleak and endograft migration were most frequently observed, whereas compliance to follow-up was low.

The effectiveness of intralesional injection of platelet-rich plasma in accelerating the healing of chronic ulcers: an experimental and clinical study

The purpose of this prospective experimental and clinical study is to evaluate the effectiveness of the intralesional injection of platelet-rich plasma (PRP), in the management of non-healing chronic wounds. Skin defects were created in the ears of 20 white New Zealand rabbits. In the study group, autologous PRP was injected intralesionally. The control group was treated conservatively. Nineteen out of 20 cases of the study group healed within a mean time of 24·9 days. In the control group, seven defects healed within a mean period of 26·7 days, seven ulcers did not heal at day 28 and in six cases a full thickness ear defect was recorded. For a 3-year period, 26 patients with chronic ulcers underwent surgical debridement and intralesional injection of PRP. A histological study was performed before and 7 days after PRP injection. Ten patients healed within a mean period of 7 weeks. In 16 cases, PRP prepared the wound bed for the final and simpler reconstructive procedure. Intralesional injection is a newly described method for application of PRP and represents an effective therapeutic option when dealing with non-healing wounds.

Management of concurrent colorectal cancer and vascular disease in the endovascular era

Concurrent colorectal cancer (CRC) and vascular disease, such as abdominal aortic aneurysm, represents a challenging clinical situation. Both lesions may lead to the demise of the patient and therefore should be treated. Endovascular techniques may enhance decision-making and even permit single-stage treatment.

PATIENTS AND METHODS

Retrospective review of patients in a university department with extensive endovascular experience. Between 2004 and 2010, seven patients with synchronous vascular disease and colorectal cancer were identified.

RESULTS

The mean age was 73 years, and all patients were men. Five patients had concurrent CRC and aneurysmal disease. Two had synchronous critical carotid artery stenosis and CRC. All vascular lesions were treated with endovascular techniques. All CRC were resected with open techniques. In four patients, endovascular repair followed by staged CRC resection was performed. In three patients, single-stage procedures were performed. There was one perioperative death, for a mortality of 14.3% in our series. There were no graft infections.

CONCLUSIONS

Priority of treating concurrent vascular disease and CRC remains a dilemma. Combined treatment with a single-stage procedure is feasible. Risk of graft infection may be lower than expected.

Endovascular repair of a spontaneous ilio-iliac fistula presenting as pulmonary embolism

Spontaneous rupture of a common iliac artery aneurysm into the common iliac vein is a rare phenomenon. We report the case of a 68 year old man admitted with acute cardiac failure and massive pulmonary embolism as a complication of a spontaneous ilio-iliac fistula, secondary to aneurysmal rupture. The aneurysm was successfully excluded using an aorto-uni-iliac stent graft. No complications were noted at 9 months follow-up. Arteriovenous fistulae should be considered in patients with aortic or iliac aneurysms who develop a pulmonary embolism or symptoms of venous congestion. Endovascular repair of these pathologies is a feasible therapeutic option; however long term results remain unknown.

Emergency endovascular treatment of popliteal aneurysms

Popliteal artery aneurysm (PAA), despite being rare, is the most common peripheral aneurysm. It can present as acute thrombosis and occlusion of the aneurysmal segment, and distal embolization, causing either chronic or acute limb ischemia. It has traditionally been treated with open surgical reconstruction. Endovascular repair of PAAs has recently been applied electively with a favourable early and mid-term outcome; however there is a lack of reports on the endovascular treatment of PAAs presenting with acute complications. This report describes the treatment of a thrombosed PAA in a 58 year old male using an endovascular stent-graft and also provides a systematic review of the literature on the emergency endovascular treatment of PAAs.

Abdominal aortic aneurysm: a review of the genetic basis

BACKGROUND

Abdominal aortic aneurysm (AAA) is a complex disease with a largely unknown pathophysiological background and a strong genetic component. Various studies have tried to link specific genetic variants with AAA.

METHODS

Systematic review of the literature (1947-2009).

RESULTS

A total of 249 studies were identified, 89 of which were eventually deemed relevant to this review. Genetic variants (polymorphisms) in a wide variety of genes, most of which encode proteolytic enzymes and inflammatory molecules, have been associated with AAA development and progression.

CONCLUSION

The genetic basis of AAA remains unknown, and most results from ''candidate-gene'' association studies are contradictory. Further analyses in appropriately powered studies in large, phenotypically well-characterized populations, including genome-wide association studies, are necessary to elucidate the exact genetic contribution to the pathophysiology of AAA.

Can statins suppress the development of abdominal aortic aneurysms? A review of the current evidence

Statins possess several pleiotropic effects and have been shown in vitro and in vivo to inhibit the expression of inflammatory mediators and downregulate molecules involved in extracellular matrix (ECM) degradation. Recent observational studies in humans suggest that statins may have a role in abdominal aortic aneurysm (AAA) prevention or may even inhibit aneurysm expansion. In this review, we summarize the effects of statins on the vessel wall of aneurysmal aortas and currently available data concerning their inhibitory effects on aneurysm progression.

Quantitative evaluation of the systemic effects of transposed basilic vein to brachial artery arteriovenous fistula: a prospective study

BACKGROUND

The transposed basilic vein to brachial artery arteriovenous fistula (BBAVF) constitutes an alternative autogenous vascular access (VA) site for chronic hemodialysis (HD); however, the hemodynamic effects of this procedure have not been adequately studied. The purpose of this study is to evaluate the effects of BBAVF on systemic arterial pressure, cardiac function, and upper limb ischemia (ischemic steal syndrome) utilizing reproducible quantitative methods.

METHODS

Ten consecutive patients (eight males; mean age: 65.10+/-2.87 yrs) scheduled to undergo a brachial-basilic vein transposition were included, excluding patients with cardiac failure. Blood flow volume at the level of the AVF, systemic arterial pressure (SAP), cardiac output (CO) and digital brachial index (DBI) were measured intra-operatively, before and after the creation of the BBAVF, and post-operatively on the 30th post-operative day and on the 3rd post-operative month.

RESULTS

SAP and DBI at 30 days and 3 months post-operatively were significantly lower compared to baseline. CO at 30 days and 3 months post-operatively was significantly higher compared to baseline; however, none of the patients developed cardiac failure. DBI remained >or=0.6 at 3 months, except in one case (0.59). Blood flow volume at the level of the AVF was positively correlated with CO levels on the 30th post-operative day. Mean clinical follow-up was 12 months (range: 4-15 months). In two cases (20%) the AVF was thrombosed (4th and 10th post-operative month).

CONCLUSION

This prospective quantitative study proves that the BBAVF does impact significantly upon SAP, CO, and DBI; however, it is safe in terms of high-output cardiac failure and ischemic steal syndrome. The authors state that they do not have any commercial, proprietary, or financial interest in any products or companies described in this article.

Minimally invasive endovascular intervention in emergent and urgent thoracic aortic pathologies: single center experience

INTRODUCTION

We report mid-term results from the endovascular treatment of acute thoracic aortic pathologies in a single center.

METHODS

We retrospectively interrogated our clinical database and identified the following patients who were treated for an acute thoracic aortic pathology during a 3-year period (January 2003 to February 2006) with the deployment of a thoracic endograft: 8 male patients diagnosed with a thoracic aortic pseudoaneurysm and/or a thoracic aortic disruption following blunt chest trauma; 1 male patient with a large mobile mural thrombus of the descending thoracic aorta; 1 patient with an aortobronchial fistula; and 8 patients with a symptomatic descending thoracic aortic aneurysm.

RESULTS

Complete exclusion of the lesion was achieved in all patients. No procedure-related deaths occurred. Postoperative complications included one case of a distal type 1 endoleak, repaired with re-intervention and deployment of an extension graft, and 1 case of moderate graft kinking without further complications.

CONCLUSION

The endovascular treatment of acute thoracic aortic pathologies is technically feasible and safe. Early and intermediate results are promising.

Non-activated autologous platelet-rich plasma for the prevention of inguinal wound-related complications after endovascular repair of abdominal aortic aneurysms

The endovascular repair (EVAR) of abdominal aortic aneurysms (AAAs) usually involves the surgical exposure and catheterization of the femoral arteries. Several inguinal surgical wound-related complications have been reported postoperatively. The aim of this report was to evaluate the safety and efficacy of intraoperative application of autologous platelet-rich plasma (PRP) for the prevention of wound-related complications in AAA EVAR. The authors conducted a patient- and assessor-blinded controlled trial involving 100 subjects undergoing EVAR of an AAA. PRP was produced using an autologous platelet separator and was applied, without prior thrombin activation, in 50 patients eligible for inclusion. The results were compared with a control group of 50 patients who underwent AAA EVAR within the same time period. The primary outcome was the difference in postoperative hospital stay. Secondary outcomes included subjective assessment of wound healing and wound-related complications. Age, sex, and other comorbidities related to wound healing were not significantly different between cases and controls. One patient treated with PRP developed a unilateral wound infection with lymphorrhea, and two patients developed a bi-lateral superficial infection. Twelve patients within the control group developed a wound-related complication. The postoperative hospitalization was significantly lower in the PRP group. The overall surgical wound-related complications rate was also significantly lower in the PRP group. Application of non-thrombin-activated PRP seems to prevent major postoperative wound-related complications (p = .026) and shorten postoperative hospital stay duration after femoral artery exposure and catheterization for AAA EVAR (mean, 4.48 +/- 0.48 vs. 6.14 +/- 0.39 days).

Non-randomized, prospective, multi-centre evaluation of the ABSOLUTE .035 peripheral self-expanding stent system for occluded or stenotic superficial femoral or proximal popliteal arteries (ASSESS Trial): acute and 30-day results

AIM

The aim of the paper was to investigate the performance of the ABSOLUTE .035 Peripheral Self-Expanding Stent System in preventing restenosis of superficial femoral or proximal popliteal arteries. Due to a lack of large controlled trials proving its long-term durability femoropopliteal artery stenting is still a matter of debate. In this paper we report the study design, the acute and short-term results of a prospective European registry on the treatment of TASC B and C femoropopliteal lesions with the use of the ABSOLUTE stent.

METHODS

This prospective, non-randomized, multi-centre study enrolled 122 patients with symptomatic peripheral occlusive disease at 14 sites in Europe. Patients were included with obstructed femoropopliteal arteries. Key inclusion criteria were de novo lesions > or = 4.0 mm and < or = 7.0 mm in diameter, and > or = 40 mm and < or = 200 mm in length. Single target vessel treatment had to be performed with a maximum of three stents.

RESULTS

Mean target lesion length was 108 +/- 44 mm (range 22.2 to 200 mm) and mean reference vessel diameter 4.6 +/- 0.8 mm by quantitative angiography; 71% of the lesions analyzable by quantitative angiography (QA) had total occlusions. A total of 227 stents were implanted, 224 of which were deployed successfully (98.7%). Mean percentage of diameter stenosis was reduced from 90.9 +/- 15.5 % (range 41.3 to 100) to 19.0 +/- 8.4% (range 2.3 to 41.5). Device and procedural success were 83.6% each whereas technical success reached 100%. Sixteen lesions had a > or = 30% residual stenosis post-procedure, 6 of them (37.5%) rated as being calcified. Eleven patients experienced major complications (9.1%) and 6 patients experienced minor complications (5%) within 30 days. Duplex ultrasound based 1-month restenosis rate was 9.3%. Target lesion revascularization (TLR) and target vessel revascularization (TVR) rates were 0.8% and 1.7%, respectively and amputation rate was 0.8%. Mean ankle-brachial index (ABI) at rest and after exercise increased significantly from baseline to 30 days follow-up by 0.63 +/- 0.20 to 0.94 +/- 0.17 and from 0.44 +/- 0.23 to 0.85 +/- 0.21, respectively (P<0.001 each).

CONCLUSION

The treatment of TASC B and C femoro-popliteal lesions with use of the ABSOLUTE stent is safe and feasible. Short-term follow-up documents persistent improvement of hemodynamics. The 6- and 12-month data have to be awaited for further conclusions:

Carotid Artery Stent Placement with Embolic Protection: Single-Center Experience

PURPOSE

To evaluate the efficacy of carotid artery stent placement with embolic protection.

MATERIALS AND METHODS

During a 2-year period (May 2003 to April 2005), 232 patients underwent carotid artery stent placement with the Acculink RX stent-graft and an embolic protection device. There were 150 men (mean age,70 years; age range, 58-85 years) and 82 women (mean age, 76 years; age range, 56-82 years). One hundred sixty-five patients were symptomatic and 67 were asymptomatic. All patients were at high risk for carotid endarterectomy.

RESULTS

The procedure was technically successful in 231 patients. The procedure was stopped in one patient due to asystole. In three patients, a cervical approach was necessary owing to aortic arch anatomy. During the procedure,11 patients (4.74%) experienced bradycardia and two developed a major stroke (0.86%). The mean follow-up was 30 months (range, 12-36 months). Four patients died. No stent occlusion was observed. During the late follow-up period(>30 days), two patients (0.86%) had minor strokes, three (1.29%) had nonfatal transient ischemic attacks, and seven(3.01%) had myocardial infarctions.

CONCLUSION

Carotid artery stent placement with cerebral protection by using the specific devices compares favorably to previously reported surgical results.

Endovascular Treatment of Descending Thoracic Aortic Aneurysms with the EndoFit Stent-Graft

OBJECTIVE

To evaluate the mid-term feasibility, efficacy, and durability of descending thoracic aortic aneurysm (DTAA) exclusion using the EndoFit device (LeMaitre Vascular).

METHODS

Twenty-three (23) men (mean age 66 years) with a DTAA were admitted to our department for endovascular repair (21 were ASA III+ and 2 refused open repair) from January 2003 to July 2005.

RESULTS

Complete aneurysm exclusion was feasible in all subjects (100% technical success). The median follow-up was 18 months (range 8-40 months). A single stent-graft was used in 6 cases. The deployment of a second stent-graft was required in the remaining 17 patients. All endografts were attached proximally, beyond the left subclavian artery, leaving the aortic arch branches intact. No procedure-related deaths have occurred. A distal type I endoleak was detected in 2 cases on the 1 month follow-up CT scan, and was repaired with reintervention and deployment of an extension graft. A nonfatal acute myocardial infarction occurred in 1 patient in the sixth postoperative month. Graft migration, graft infection, paraplegia, cerebral or distal embolization, renal impairment or any other major complications were not observed.

CONCLUSION

The treatment of DTAAs using the EndoFit stent-graft is technically feasible. Mid-term results in this series are promising.