Alessandro Alessi Innocenti

Surgical treatment of visceral artery aneurysms: A 25-year experience

OBJECTIVE The aim of this study was to analyze our 25-year experience with surgical treatment of visceral artery aneurysms (VAAs), with particular attention paid to early and long-term results. MATERIALS AND METHODS From January 1982 to September 2007, 55 patients (32 males, 58%, and 23 females, 42%) underwent surgical treatment of 59 VAAs. Only one patient was treated with an endovascular procedure. Mean patient age was 59.3 years (range, 36-78 years). The site of aneurysmal disease was splenic artery in 30 (50.8%) cases, renal artery in nine (15.2%) cases, common hepatic artery in seven (11.9%) cases, pancreaticoduodenal artery in four (6.8%) cases, celiac trunk in three (5.1%) cases, superior mesenteric artery in two (3.4%) cases, and gastroduodenal, inferior mesenteric, middle colic and right gastroepiploic in one (1.7%) case for each artery. Two (3.6%) patients had multiple VAAs. In five (9.1%) patients, an abdominal aortic aneurysm coexisted. Early results in terms of mortality and major complications were assessed. Follow-up consisted of clinical and ultrasound examinations at 1 and 12 months, and yearly thereafter. Long-term results in terms of survival and aneurysm-related complications were analyzed. RESULTS In all but two cases, elective intervention in asymptomatic patients was performed. Two (3.6%) patients had a ruptured aneurysm (one pancreaticoduodenal artery and one middle colic artery). The one perioperative death was due to an acute pancreatitis in a patient operated on for a giant inflammatory splenic artery aneurysm, yielding a perioperative mortality rate of 1.8%. Two major complications (retroperitoneal hematoma and acute pancreatitis) were recorded. Mean duration of follow-up was 82.1 months (range, 0-324 months). Estimated 10-year survival rate was 79.5%. During follow-up two aneurysm-related complications occurred, with an estimated 10-year, aneurysm-related, complication-free survival rate of 75.2%. CONCLUSION In the era of minimally invasive therapeutic approaches, elective open surgical treatment of visceral artery aneurysms is safe and effective, and offers satisfactory early and long-term results.

Early and long-term results of surgical treatment of splenic artery aneurysms

BACKGROUND This retrospective study was conducted to describe the presentation, surgical treatment, and follow-up of patients with splenic artery aneurysms. METHODS From 1982 to 2000, 1,952 patients with abdominal aneurysms were referred to our department; 15 had splenic artery aneurysms. None had ruptured. All were operated on. RESULTS Fourteen complete and 1 partial aneurysmectomies were carried out. Arterial continuity was restored in 10, by end-to-end anastomosis, and 4 had splenectomies. In 1 patient the spleen was preserved without arterial reconstruction. There were no deaths. Morbidity was restricted to 1 patient with a limited, asymptomatic splenic infarction. Eleven patients were followed up for a mean 19.7 months. No deaths or major complications were recorded. Reconstructed splenic arteries were patent in all cases without atrophy or new cases of splenic infarction. CONCLUSIONS Elective surgery for splenic artery aneurysms is safe. Arterial reconstruction allows good early and long-term results. In some cases splenectomy may be unavoidable.

Early and long-term comparison of endovascular treatment of iliac artery occlusions and stenosis

OBJECTIVES This study evaluated early and long-term results of endovascular treatment of iliac artery occlusions and compared these outcomes with those in patients treated for stenotic lesions. METHODS During a 10-year period ending in January 2010, 223 endovascular procedures to treat aortoiliac occlusive disease (PAD) were performed. All patients were prospectively enrolled in a dedicated database. The intervention was performed for iliac occlusion in 109 patients (group 1) and for iliac stenosis in 114 (group 2). Early results were analyzed and compared by χ² and Fisher exact tests. Follow-up consisted of clinical examination and duplex scanning at discharge, ≤ 3 months, at 6 and 12 months, and yearly thereafter. Follow-up results were analyzed with Kaplan-Meier curves and compared with the log-rank test. RESULTS The two groups had similar risk factors for atherosclerosis and comorbidities. Critical limb ischemia was more common in group 1 (20.5%) than in group 2 (8.5%; P = .01). Intraoperative technical details were similar, except for a higher percentage of brachial and contralateral femoral access and more frequent use of nitinol stents in group 1. Two immediate technical failures occurred, one in both groups, requiring immediate conversion to surgical bypass. Four intraoperative iliac ruptures occurred, two in each group; all were successfully treated with covered stents. An additional 10 immediate complications occurred (8 in group 1; 2 in group 2), one of which required conversion to open surgical bypass. The cumulative rate of perioperative complications was 9% in group 1 and 3.5% in group 2 (P = .08). Primary patency at 30 days was 97.3% and 98.7%, respectively. Mean duration of follow-up was 28.4 months; 203 patients (91%) had a regular postoperative follow-up visit. At 60 months, primary patency in group 1 vs group 2 was 82.4% vs 77.7% (P = .9), assisted primary patency was 90.6% vs 85.5% (P = .4), and estimated secondary patency was 93.1% vs 92.8% (P = .3). The cumulative rate of reintervention during follow-up (excluding reinterventions performed in the perioperative period) was 2.5% in group 1 and 12.5% in group 2 at 60 months (P = .09). Univariate analysis in group 1 failed to find any of the examined risk factors significantly affected long-term primary patency rates. CONCLUSIONS In our experience, endovascular treatment of iliac occlusions provides excellent early and long-term results, similar to those obtained in the treatment of stenotic lesions.

Comparison of Early and Midterm Results of Open and Endovascular Treatment of Popliteal Artery Aneurysms

BACKGROUND Aim of this study was to retrospectively compare perioperative (<30 days) and 2-year results of open and endovascular management of popliteal artery aneurysms (PAAs) in a single-center experience. METHODS From January 2005 to December 2010, 64 PAAs in 59 consecutive patients were operated on at our institution; in 43 cases, open repair was performed (group 1), whereas the remaining 21 cases had an endovascular procedure (group 2). Data from all the interventions were prospectively collected in a dedicated database, which included main preoperative, intraoperative, and postoperative parameters. Early results in terms of mortality, graft thrombosis, and amputation rates were analyzed and compared by χ(2) text or Fisher exact text. The surveillance program consisted of clinical and ultrasonographic examinations at 1, 6, and 12 months and yearly thereafter. Follow-up results (survival, primary and secondary patency, limb salvage) were analyzed by Kaplan-Meier curves, and differences in the two groups were assessed by log-rank test. RESULTS There were no differences between the two groups in terms of sex, age, risk factors for atherosclerosis, and comorbidities; PAAs were symptomatic in 48% of cases in group 1 and in 29% in group 2 (P = 0.1). Fifteen patients with mild-to-moderate acute ischemia due to PAA thrombosis underwent preoperative intra-arterial thrombolysis, 13 in group 1 and 2 in group 2. In open surgery group, nine cases were treated with aneurysmectomy and prosthetic graft interposition, and in seven cases, the aneurysm was opened and a prosthetic graft was placed inside the aneurysm. In 27 cases, ligation of the aneurysm with bypass grafting (21 prosthetic grafts and 6 autologous veins) was carried out. In group 2, 20 patients had endoprosthesis placement, whereas in the remaining patient, a multilayer nitinol stent was used. There was one perioperative death in a patient of group 2 who underwent concomitant endovascular aneurysm repair and PAA endografting. Cumulative 30-day death and amputation rate was 4.5% in group 1 and 4.7% in group 2 (P = 0.9). Follow-up was available in 61 interventions (96%) with a mean follow-up period of 22.5 months (range: 1-60). Estimated primary patency rates at 24 months were 78.1% in group 1 and 59.4% in group 2 (P = 0.1). Freedom from reintervention rates at 24 months were 79% in group 1 and 61.5% in group 2 (P = 0.2); estimated 24-month secondary patency rates were 81.6% in group 1 and 78.4% in group 2 (P = 0.9), and freedom from amputation rates were 92.7% and 95%, respectively (P = 0.7). CONCLUSIONS Endovascular treatment of PAAs provided, in our initial experience, satisfactory perioperative and 1-year results, not significantly different from those obtained with prosthetic open repair in patients with similar clinical and anatomical status. There is, however, a trend toward poorer primary patency rates among patients endovascularly treated, who also seem to require more frequently a reintervention.

Early and long-term results of carotid endarterectomy in diabetic patients

PURPOSE To evaluate results of carotid endarterectomy (CEA) in diabetic patients in a large single-center experience. METHODS Over a 13-year period ending in December 2008, 4305 consecutive CEAs in 3573 patients were performed. All patients were prospectively enrolled in a dedicated database. Interventions were performed in diabetic patients in 883 cases (20.5%; group 1) and in nondiabetics in the remaining 3422 (79.5%; group 2). Early results in terms of 30-day stroke and death rates were analyzed and compared. Follow-up results were analyzed with Kaplan-Meier curves and compared with log-rank test. RESULTS Diabetic patients were more likely to be females and to have coronary artery disease, peripheral arterial disease, hyperlipemia, and arterial hypertension than nondiabetics. There were no differences between the two groups in terms of preoperative clinical status or degree of carotid stenosis. Interventions were performed under general anesthesia with somatosensory-evoked potentials (SEPs) monitoring in 67% of the patients in both groups, while the remaining interventions were performed under clinical monitoring. Shunt insertion (14% and 11%, respectively) and patch closure rates (79% and 76%, respectively) were similar between the two groups. There were no differences between the two groups in terms of neurological outcomes, while the mortality rate was higher in group 1 than in group 2 (P = .002; odds ratio [OR], 3.5; 95% confidence interval [CI], 1.5-8.3); combined 30-day stroke and death rate was significantly higher in group 1 (2%) than in group 2 (0.9%; P = .006; 95% CI, 1.2-3.9; OR, 2.2). At univariate analysis, perioperative risk of stroke and death in diabetic patients was significantly higher in patients undergoing intervention with SEP cerebral monitoring (95% CI, 0.9-39.9; OR, 5.9; P = .01), and this was also confirmed by multivariate analysis (95% CI, 1.1-23.1; OR, 8.3; P = .04). The same analysis in nondiabetics demonstrated that again the need for general anesthesia significantly increased perioperative risk, but this was not significant at multivariate analysis. Follow-up was available in 96% of patients, with a mean duration of 40 months (range, 1-166 months). There were no differences between the two groups in terms of estimated 7-year survival (87.3% and 88.8%, respectively; 95% CI, 0.57-1.08; OR, 0.8) and stroke-free survival (86.8% and 88.1%, respectively; 95% CI, 0.59-1.07; OR, 0.8). Diabetic patients had decreased severe (>70%) restenosis-free survival rates at 7 years than nondiabetics (77.4% and 82.2%, respectively; 95% CI, 0.6-1; OR, 0.8; P = .05). Univariate analysis demonstrated again that the use of instrumental cerebral monitoring significantly decreased stroke-free survival in diabetics (P = .01; log rank, 10.1), and this was also confirmed by multivariate analysis (95% CI, 1.7-17.7; OR, 5.4; P = .005). CONCLUSIONS In our experience, the presence of diabetes mellitus increases three-fold the risk of perioperative death after CEA, while there are no differences with nondiabetics in terms of perioperative stroke. However, the rate of stroke and death at 30 days still remains below the recommended standards. During follow-up, this difference becomes negligible, and results are fairly similar to those obtained in nondiabetics. Particular attention should be paid to patients undergoing intervention under general anesthesia, who seem to represent a subgroup of diabetics at higher perioperative risk, suggesting neurologic monitoring should be used when possible.

Early and Intermediate Results of Elective Endovascular Treatment of True Visceral Artery Aneurysms

BACKGROUND To retrospectively analyze early and follow-up results of endovascular management of visceral artery aneurysms (VAAs) in a single-center experience. METHODS From 2007 to June 2013, 26 consecutive elective endovascular interventions for VAAs were performed in 26 patients; preoperative, intraoperative, and postoperative data were prospectively collected in a dedicated database. Early (<30 days) and follow-up results were evaluated. RESULTS The site of aneurysm was splenic artery in 17 patients, common hepatic artery in 3 patients, renal artery and pancreaticoduodenal artery in 2 cases each, and gastroduodenal artery and celiac trunk in one case each. All the lesions were asymptomatic, and the mean diameter was 22.8 mm. Interventions consisted in coiling in 19 cases; in 4 patients a covered stent was placed, whereas the remaining 3 patients had a multilayer stent. Technical success was 89%. There were no perioperative deaths; 1 patient with splenic artery aneurysm had coils migration with symptomatic splenic infarction and underwent successful redo coils packing. Median duration of follow-up was 18 months. During follow-up, 1 aneurysm-unrelated death occurred. One asymptomatic thrombosis of a treated vessel was recorded, with a 2-year estimated patency rate of 91%. Mean aneurysmal diameter at the latest follow-up was 20.2 mm (P = 0.001 in comparison with preoperative values; 95% confidence interval 1.9-5.2). Complete exclusion of the aneurysm occurred in all but 1 patient, who had a limited increasing in the diameter of its splenic aneurysmal sac after coiling. Another patient developed a more distal aneurysm of the splenic artery after 24 months. No reinterventions were required. Freedom from aneurysm-related complications at 2 years was 72.9% (Standard Error, 0.09). CONCLUSIONS In our experience, endovascular treatment of VAA, when feasible, provided excellent perioperative results with low rates of complications and reinterventions. Even if the risk of developing aneurysm-related complications during follow-up is substantial, most of them can be watched without the need for repeated interventions.

Carotid endarterectomy in female patients

OBJECTIVES To evaluate early and late results of carotid endarterectomy (CEA) in female patients in a large single center experience. METHODS Over a 12-year period ending in December 2007, 4009 consecutive primary and secondary CEAs in 3324 patients were performed at our institution. All patients were prospectively enrolled in a dedicated database containing pre-, intra-, and postoperative parameters. Patients were female in 1200 cases (1020 patients; Group 1) and male in the remaining 2809 (2304 patients, Group 2). Early results in terms of intraoperative neurological events and 30-day stroke and death rates were analyzed and compared. Follow-up results were analyzed with Kaplan Meier curves and compared with log-rank test. RESULTS Patients of Group 1 were more likely to have hyperlipemia, diabetes, and hypertension; patients of Group 2 were more likely to be smokers and to have concomitant coronary artery disease (CAD) and peripheral arterial disease (PAD). There were no differences in terms of clinical status or degree of stenosis. Patients of Group 2 had a significantly higher percentage of contralateral carotid artery occlusion than patients in Group 1 (6.9% and 3.9%, respectively; P < .001). Thirty-day stroke and death rates were similar in the two groups (1.2% for both groups). Univariate analysis demonstrated the presence of CAD, PAD, diabetes, and contralateral carotid artery occlusion to significantly affect 30-day stroke and death rate in female patients. At multivariate analysis, only diabetes (odds ratio [OR] 3.6, 95% confidence interval [CI] 0.1-0.9; P = .05) and contralateral occlusion (OR 7.4, 95% CI 0.03-0.6; P = .006) were independently associated with an increased perioperative risk of stroke and death. Median duration of follow-up was 27 months (range, 1-144 months). There were no overall differences between the two groups in terms of survival, freedom from ipsilateral stroke, freedom from any neurological symptom, and incidence of severe (>70%) restenosis. In contrast to male patients, univariate and multivariate analysis demonstrated that female patients with diabetes or contralateral occlusion had an increased risk of developing ipsilateral neurological events during follow-up. CONCLUSIONS Female sex per se does not represent an adjunctive risk factor during CEA, with early and long term results comparable to those obtained in male patients. However, in our study we found subgroups of female patients at higher surgical risk, requiring careful intra- and postoperative management.

Combined Carotid and Cardiac Surgery: Improving the Results

BACKGROUND Aim of this study was to analyze our experience in the last 5 years of combined carotid and cardiac surgery. METHODS During a 5-year period (January 2002-December 2006), 111 patients underwent combined carotid endarterectomy (CEA) and coronary artery bypass grafting (CABG) (group 1), while 1,446 patients underwent isolated CEA (group 2). Perioperative outcomes in the two groups were compared using chi(2) and Fishers exact tests to analyze neurological deficits, cardiac events, and death at 30 days. Results during follow-up were analyzed using Kaplan-Meier survival curves, and both groups were compared using the log-rank test. RESULTS Immediate postoperative neurological deficits occurred more frequently in group 1 patients (2.5 vs. 0.4%, p = 0.002), with a higher incidence of transient ischemic attacks in group 1; however, there was no difference in the incidence of stroke (1% group 1 vs. 0.6% group 2, p = n.s.). Mortality rate was increased in the combined surgery group (3.5 vs. 0.5%, p < 0.001). Combined stroke/myocardial infarction/death rate at 30 days was 6.3% in group 1 compared with 1.4% in group 2, p = 0.001. Perioperative stroke/myocardial infarction/death rate was much improved in the 55% (61/111) of patients undergoing CABG off-pump (3.3 vs. 10%, p = 0.001). Mean follow-up was 18.7 months (range, 1-60). Survival at 24 months was significantly higher in patients of group 2 compared with group 1 (99.4 vs. 91.3% respectively, p < 0.001). At 24 months, there was no significant difference between the two groups in the risk of developing ipsilateral or contralateral neurologic events (3.1% group 1 vs. 1.7% group 2). CONCLUSION In our experience, combined CEA and cardiac surgery carries a higher risk of perioperative mortality than patients undergoing isolated CEA. Whenever possible, CEA combined with off-pump CABG seems to be the therapeutic strategy of choice.

Early and midterm results of kissing stent technique in the management of aortoiliac obstructive disease.

BACKGROUND To retrospectively analyze the early and the midterm results of endovascular management of aortoiliac obstructive disease with the kissing stent technique. METHODS From January 2005 to September 2012, 229 consecutive endovascular interventions for aortoiliac obstructive disease were performed; data from all the interventions were prospectively collected in a dedicated database. In 41 patients, the kissing stent technique at the level of aortic bifurcation was performed (group 1), whereas in the remaining 188 it was not (group 2). Perioperative results were compared with chi-squared test. Follow-up results were analyzed with Kaplan-Meier curves and compared with log-rank test. RESULTS Trans-Atlantic Inter-Society Consensus II C and D lesions were present in 66% of patients in group 1 and in 28.5% in group 2 (P < 0.001), whereas iliac occlusion rather than stenosis was detected in 78% of patients in group 1 and in 50% in group 2 (P = 0.001). The mean number of placed stents was 2.5 in group 1 and 1.4 in group 2 (P < 0.001). Technical success was 100% in group 1 and 98% in group 2 (P = 0.3). The rate of perioperative complications was 7.3% in group 1 and 4.2% in group 2 (P = 0.4). At 30 days, neither deaths nor major cardiovascular complications occurred. There was no thrombosis or significant restenosis at the early postoperative follow-up visit. Mean duration of follow-up was 22 months. Primary patency rates at 4 years were 70.5% (standard error [SE], 0.09) in group 1 and 75.5% (SE, 0.06) in group 2 (P = 0.7). At the same interval, assisted primary and secondary patency and survival rates were also similar; reintervention rates were 15.5% in group 1 (SE, 0.1) and 19.5% in group 2 (SE, 0.06; P = 0.6). CONCLUSIONS The kissing stent technique provided satisfactory results in patients with obstructive aortoiliac diseases, without an increase in immediate and midterm complications, representing an effective solution in complex anatomies.

Alternative Hybrid Reconstruction for Bilateral Common and Internal Iliac Artery Aneurysms Associated with External Iliac Artery Occlusion

Purpose: To describe an alternative reconstruction for bilateral common (CIA) and internal (IIA) iliac artery aneurysms associated with external iliac artery (EIA) occlusion in a patient unfit for open surgery. Case Report: A high-risk 81-year-old man presented with contained rupture of a left CIA aneurysm in the presence of bilateral CIA and IIA aneurysms associated with complete occlusion of the left EIA and normal patency of both common femoral arteries. In an emergent procedure, the left EIA was recanalized subintimally, and the right IIA was embolized with a 14-mm Amplatzer Plug. The main body of a standard Excluder endograft was deployed just distal to the origin of the left renal artery, and the ipsilateral leg was extended into the proximal right EIA. On the contralateral side, a short 10-mm-diameter limb was inserted through a 12-F sheath and deployed in the CIA, proximal to the iliac bifurcation. Via a percutaneous left brachial artery access, 3 covered stents (9×59 mm, 10×59 mm, 10×59 mm) were deployed from the distal IIA to the endograft contralateral limb. A right-to-left femorofemoral crossover bypass graft concluded the operation. The patient was discharged on the 5th postoperative day without complications; follow-up imaging at 6 months showed patency of the stent-graft and crossover bypass, with complete exclusion of the aneurysms and no evidence of endoleak. Conclusion: This case demonstrates an effective solution for complex aortoiliac lesions using commercially available devices, underlining how an accurate knowledge of alternative endovascular techniques and materials is crucial in the management of complex cases.