Alessandro Costanzo

Our experience of popliteal vein aneurysm

Popliteal venous aneurysms (PVA) are rare and in most cases the first sign of their presence is a pulmonary embolus or other thromboembolic events. We report four cases of PVA, in two of these the first sign of their presence was an acute pulmonary embolism; in two remaining cases the diagnosis was fortuitous. Accurate evaluation of venous system of lower limb by duplex scan is important in all cases of pulmonary embolism, the anticoagulation may be ineffective in preventing pulmonary embolism and the surgical repair is the mainstay of therapy of this pathology because it is safe and effective.

Endovascular management of transplant renal artery stenosis

OBJECTIVE Most clinicians regard angioplasty with or without stent placement to be the treatment of choice for transplant renal artery stenosis (TRAS). However, published results regarding its effectiveness are heterogeneous. The aim of this study was to assess the safety and efficiency of TRAS endovascular therapy. METHODS All cases of TRAS admitted for treatment in our unit from January 2009 to December 2012 were reviewed retrospectively. The primary end point was the stenosis-free primary transplant renal artery patency. Secondary end points were freedom from reintervention, graft survival, postoperative serum creatinine level, blood pressure evolution, and the number of antihypertensive drugs pre- and postprocedure. RESULTS A total of 17 patients (10 men, 7 women) presenting with TRAS were referred to our institution. During the early post-transplantation process (<15 days), 35.2% of patients presented. The median time to presentation was 40 days. The predominant presentation was graft function alteration (82.3%). Percutaneous balloon angioplasty was performed in five patients (29.4%), while stenting was performed in the remaining 12 patients (70.6%). The stenosis-free primary patency rate and freedom from reintervention rate were 76.5% and 88.2%, respectively. The median follow-up was 19.6 months with 88.2% graft survival. There were no mortalities throughout the follow-up period. Serum creatinine levels decreased significantly from 186 μmol/L (range, 148-310 μmol/L) preoperatively to 160 μmol/L (range, 127-236 μmol/L at discharge (P = .0036). The glomerular filtration rates increased from 32.1 mL/min (range, 21.4-45.8 mL/min) to 41.7 mL/min (range, 27.5-52.4 mL/min; P = .004). Systolic and diastolic blood pressure varied from 140 mm Hg (range, 137-157 mm Hg) and 75 mm Hg (range, 70-80 mm Hg), to 135 mm Hg (range, 130-147 mm Hg and 80 mm Hg (range, 73-80 mm Hg), respectively (P = .11 and P = .36). The preoperative number of antihypertensive medications was 2 (range, 1-3) and remained unchanged (P = .33). CONCLUSIONS The endovascular management of TRAS is safe and presents a high rate of technical success with low morbidity. Its impact on serum creatinine levels is significant in our experience. However, the blood pressure items do not seem to improve postoperatively.

Long-Term Preservation of Native Arteriovenous Dialysis Fistulas

Preservation of native arteriovenous fistulas (AVFs) in the long term can be technically challenging. Various anatomic or functional problems can occur and multiple open and/or endovascular interventions may be required for extended preservation of native accesses. In this report, we review vascular access maintenance in a 72-year-old woman during a 5-year period. Multiple complications of her native radiocephalic AVF included recurrent occlusions, a central venous stent fracture and symptomatic venous outflow stenosis. We present this case to illustrate the various techniques and combination of approaches used in the long-term preservation of a native AVF.

Primary tibial vein aneurysm with recurrent pulmonary emboli

We report the case of a 42-year-old man with pleuritic chest pain, shortness of breath, and associated tachycardia. Three months before, he had been treated for similar features with the diagnosis of pulmonary emboli. Computed tomography scan showed multiple bilateral pulmonary emboli. He had no clinical evidence of deep venous thrombosis, but an accurate venous duplex examination revealed a thrombosis of the posterior tibial vein aneurysm. Thrombolysis, a temporary inferior cava filter (ICV filter), and tangential aneurysmectomy and lateral venorrhaphy were performed. Accurate duplex scan evaluation of lower limb venous system is mandatory in all cases of pulmonary embolism; anticoagulation may be ineffective in preventing pulmonary embolism, and the surgical repair is treatment of choice of this pathology because it is safe and effective.

De Novo Periaortic Fibrosis after Endovascular Aortic Repair

We report a case of a 63-year-old man presenting with abdominal pain and hydronephrosis secondary to periaortic fibrosis (PAF) 8 months after an endovascular aortic repair (EVAR) using a woven polyester bifurcated graft. De novo delayed PAF after open repair is rare and even more infrequent after EVAR. All 3 previously reported cases occurred after woven polyester grafts and no reported cases after polytetrafluorethylene grafts. Management included steroidal anti-inflammatory treatment and bilateral double J tube placement. Satisfactory results were obtained.

Early results of percutaneous arteriovenous fistula creation with the Ellipsys Vascular Access System

Objective: We reviewed our initial experience creating a percutaneous arteriovenous fistula (pAVF) using a thermal resistance anastomosis device with proximal radial artery inflow. Methods: A retrospective review was conducted of all patients who underwent a pAVF creation procedure between May 2017 and October 2017. Primary end points of the study were technical success, patency by Doppler ultrasound examination or angiography, flow levels achieved, time to first use, and pAVF‐related complications. Results: A pAVF was attempted in 34 patients with technical success in 33 individuals (97%). Patency of the pAVF was 94%. Mean access flow was 946 mL/min (brachial artery measurement) at the latest follow‐up visit (53‐229 days; average, 141 days). At 6 weeks, all fistulas have been used or were ready for dialysis by clinical examination or ultrasound examination. Only one patient required superficialization of the upper arm cephalic vein by lipectomy. There were no adverse events related to the pAVF creation or use, nor was there need for further interventions. Conclusions: Successful pAVFs with proximal radial artery inflow were created with excellent initial results regarding technical success, patency, and safety. Advantages include avoidance of a surgical incision, short procedure times, good acceptance by patients, prompt access maturation, moderate flow, and low‐pressure access, with possible reduction of risk for ischemic complications. Avoidance of vessel manipulation and side branch ligation might reduce risk of thrombosis and improve long‐term patency and reduce need for further interventions. These early findings need to be confirmed in larger and longer follow‐up studies.

Safety and efficiency of ultrasound-guided intermediate cervical plexus block for carotid surgery

OBJECTIVE Since stroke and myocardial ischaemia are major causes of perioperative morbidity and mortality associated with carotid endarterectomy, monitoring the brain and ensuring the best haemodynamic stability are important goals of the management. As regional anaesthesia was reported to improve haemodynamic stability during carotid endarterectomy (CEA), we conducted a prospective observational study on the efficacy and safety of ultrasound-guided intermediate cervical plexus blocks (CPB), with early (immediate postoperative) and mid-term (day 30) outcomes in awake patients undergoing CEA. METHODS After the ethics committee approval, 50 patients undergoing a carotid endarterectomy with CPB from April 2011 to May 2013 were included. Anaesthesia and surgical dissection parameters, early complications and haemodynamic stability were recorded, as well as neurologic and cardiac outcomes initially and one month later. RESULTS Cervical space was easy to locate by ultrasound in 90% of the patients. The quality of anaesthesia and surgical dissection was good in 86 and 88% of patients, respectively. No conversion to GA was required, secondary to a lack of analgesia. Two patients (4%) had severe hypotension (<100mmHg). Three patients required a shunt after carotid clamping for loss of consciousness with a favourable neurological outcome. We observed one elevation of cTnI (0.95ng·ml(-1)) without ECG change and 1 death occurred after a postoperative haemorrhagic stroke. CONCLUSIONS The present work reports our first 50 cases of intermediate CPB using ultrasound guidance. The results underline that this technique is easy to perform, safe and reliable, provided good surgical conditions with continuous intraoperative neurologic monitoring and stable haemodynamics are respected.

Tagliatelle technique for arteriovenous fistula creation using a great saphenous vein semipanel graft

Lower limb arteriovenous (AV) access creation can be attempted in patients where upper limb options are exhausted. Utilization of the great saphenous vein as a conduit for AV access has been limited due to its small diameter and resistance to dilatation. Lower limb AV fistulas today are mostly either prosthetic grafts with high rates of infection and thrombosis or transposition of the femoral vein that can lead to limb-threatening venous hypertension. In this report, we describe an optimized technique for reconstruction of the great saphenous vein to serve as a dialysis conduit. This semipanel graft reconstruction effectively doubles the diameter of the conduit without disruption of the deep venous circulation and also mitigates the requirement for a venovenous anastomosis.

Resection of puncture site necrosis over an arteriovenous fistula: Endoclamp use for preservation of cannulation sites:

Skin necrosis overlying an arteriovenous fistula at the cannulation site is a common and potentially life-threatening problem, often associated with underlying aneurysm formation. Arteriovenous fistula-skin necrosis generally requires resection of surrounding skin margins and the underlying aneurysmal vessel wall, allowing repair with healthy tissue of the arteriovenous fistula in addition to closure of soft tissue and skin. In patients with insufficient fistula length, salvage of these arteriovenous fistulas may result in difficult or insurmountable cannulation issues leading to attempts at one-needle cannulation dialysis or, most often, catheter placement. Pre-existing stents or extensive calcification may add to the technical challenge of gaining proximal and/or distal control. We describe our technique for dealing with such arteriovenous fistula-skin necrosis lesions utilizing endo-occlusion with an angioplasty balloon for vascular control, allowing a limited incision and tissue resection with preservation of arteriovenous fistula cannulation length.

Drug eluting balloon angioplasty for assisted maturation of failing fistulae

Objective: To present our experience of balloon-assisted maturation with drug-eluting balloon dilation in patients with recurrent failing arteriovenous fistulae. Case series: Three patients (all males, mean age 71 years) with a complex history of failed attempts at native fistula creation underwent surgical creation of arteriovenous fistulae. Two patients had a two-stage brachio-brachial fistula and 1 had a brachio-cephalic fistula that also required subsequent elevation. After a few weeks of preserved patency with a thrill detected clinically, all patients had a gradual deterioration of flow manifested with loss of thrill and multiple severely stenotic lesions of neo-intimal hyperplasia seen on duplex ultrasound. All 3 non-maturing native arteriovenous fistulae had 1 or more angioplasties with regular balloons that were initially successful; however, they rapidly deteriorated with a loss of thrill and a recurrence of multiple stenosis. Drug-eluting balloon dilation was used subsequently as a last resort to save these failing fistulae. All procedures were successful with the preservation of patency and adequate fistula flow (>600 mL/min) during the follow-up period (4-8 months, mean 6 months), and all patients received successful dialysis with 2-needle cannulation of their fistulae. There were no adverse events during the study period. Conclusions: Drug-eluting balloon angioplasty was to salvage nonmaturing fistulae with durable results in complex patients where conventional treatment had previously failed. Drug-eluting balloons may provide a useful treatment option for patients prone to multiple access failures due accelerated neo-intimal hyperplasia.