Antonio Freyrie

Off-the-shelf multibranched endograft for urgent endovascular repair of thoracoabdominal aortic aneurysms

Objective: The aim of this paper was to report early and midterm results of endovascular repair of urgent thoracoabdominal aortic aneurysms (TAAAs) by the off‐the‐shelf multibranched Zenith t‐Branch endograft (Cook Medical, Bloomington, Ind). Methods: Between January 2014 and April 2016, all patients with urgent TAAAs (asymptomatic with diameter >8 cm, symptomatic, or ruptured TAAAs) and aortoiliac anatomic feasibility underwent endovascular repair by t‐Branch and were prospectively enrolled. Clinical, morphologic, intraoperative, and postoperative data were recorded. Follow‐up was performed by duplex ultrasound, contrast‐enhanced duplex ultrasound, and computed tomography angiography. Early end points were technical success (absence of type I or type III endoleak, loss of target visceral vessels [TVVs], conversion to open repair, or 24‐hour mortality), spinal cord ischemia, and 30‐day mortality. Follow‐up end points were survival, TVV patency, type I or type III endoleaks, and freedom from reintervention. Results: Seventeen patients (male, 71%; age, 73 ± 6 years; American Society of Anesthesiologists class 3/4, 60%/40%) affected by type II (47%), III (29%), and IV (24%) TAAAs were enrolled. The indications for t‐Branch were as follows: contained TAAA rupture, four (24%); symptomatic TAAA (pain or peripheral embolism), four (24%); and TAAA diameter ≥8 cm, nine (52%). The mean TAAA diameter was 80 ± 19 mm, with 63 TVVs. Fifteen patients (87%) needed adjunctive intraoperative procedures: 14 proximal thoracic endografts (thoracic endovascular aortic repair), 1 left carotid‐subclavian bypass, 2 endovascular hypogastric branches, and 2 surgical iliac conduits. In four cases (24%), a significant malorientation (≥60 degrees) of the main body occurred during t‐Branch deployment. Technical success was achieved in 14 cases (82%), with technical failures consisting of the loss of three renal arteries (TVV patency, 95%). Spinal cord ischemia occurred in one case (6%) with temporary paraparesis. The 30‐day mortality was 6% (one patient with ruptured type II TAAA died on postoperative day 7 of respiratory failure). Renal function worsening occurred in four patients (25%), with one case requiring permanent hemodialysis. The mean follow‐up was 11 ± 9 months. Survival at 1 month, 6 months, and 12 months was 94%, 82%, 82%, respectively. No TAAA‐related mortality and TVV occlusion occurred in the follow‐up. One type III endoleak was detected at 3 months and successfully treated. Freedom from reintervention at 1 month, 6 months, and 12 months was 88%, 82%, and 82%, respectively. Conclusions: The off‐the‐shelf multibranched endograft is a safe and effective therapeutic option for urgent total endovascular TAAA repair for which a custom‐made endograft is not obtainable in due time. However, the complex anatomy of these aneurysms needs a number of adjunctive and complex intraoperative procedures to achieve a durable repair.

Perioperative and Late Outcomes after Endovascular Treatment for Isolated Iliac Artery Aneurysms

BACKGROUNDnThe aim of the study is to report early and follow-up outcomes of the endovascular treatment with iliac endografts for isolated iliac artery aneurysms (IIAAs).nnnMETHODSnRecords of patients who underwent elective endovascular repair for IIAA (both primary and para-anastomotic) from 2005 to 2015 in 2 Italian centers were retrospectively examined. Demographic data, preoperative patient comorbidities, iliac aneurysm characteristics, contralateral iliac axis involvement, patency of hypogastric arteries and inferior mesenteric artery (IMA), and data of endovascular treatment were obtained for analysis. Early end points were technical success (TS), perioperative morbidity, clinical success (CS), freedom from reintervention (FFR) and survival. Follow-up end points were CS, FFR, survival, evolution of the aneurysmal sac, and endoleak (EL).nnnRESULTSnThirty-two IIAAs were treated through an endovascular approach in 30 patients (male 96.7%; mean age 74.2xa0yearsxa0±xa07.6, range 55-86). Aneurysms were para-anastomotic in 11 (34.4%) cases. Mean diameter was 42.9xa0±xa015.6xa0mm (range 30-100). Twenty (62.5%) aneurysms involved exclusively the common iliac artery, 7 (21.9%) the hypogastric, and 5 (15.6%) both arteries. Ipsilateral hypogastric artery was stenotic or occluded in 4 (12.5%) and 1 (3.1%) patient, respectively. Contralateral hypogastric artery was occluded in 2 (6.3%) cases. IMA was patent in 9 (30%) patients. The ostium of the hypogastric artery was preserved in 5 cases (15.6%) and voluntarily covered in 27 (84.4%). Endovascular embolization of hypogastric artery was obtained with a plug device in 8 cases (25%). Hypogastric surgical revascularization was performed in 2 cases (6.3%). TS was 96.9%. Thirty-day morbidity was 6.3% (2/32). CS was 96.9% (1 endograft limb stenosis). Thirty-day FFR was 90.6% (1 transluminal angioplasty, 2 inguinal revisions). Thirty-day survival was 100%. At 1, 3, and 6xa0years, CS was 93.4%, 85.6%, and 85.6%, respectively (1 endograft limb thrombosis, 1 endograft limb stenosis, 1 hypogastric type II EL with sac enlargement). At 1, 3, and 6xa0years, FFR was 87.5%, 76.8%, and 76.8%, respectively (1 fibrinolytic therapy and stenting, 1 stenting, 1 surgical ligation of hypogastric artery). At 1, 3, and 6xa0years, survival was 100%, 96.3%, and 81.3%, respectively. No IIAA-related deaths were reported. During follow-up, aneurysmal diameter was unchanged in 12 cases (37.5%), decreased in 19 (59.4%), and increased in 1 (3.1%). Type II EL from hypogastric artery was detected in 3 cases (9.4%) and led to sac enlargement requiring surgical treatment in 1 case.nnnCONCLUSIONSnEndovascular treatment of isolated iliac aneurysm is safe and effective, providing that strict anatomical requirements are respected. Aneurysm embolization with vascular plugs was not associated with pelvic complications in this series. Endograft stenosis and thrombosis are the most frequent complications, which can be easily managed with endovascular approaches.

The Role of Simulation in Boosting the Learning Curve in EVAR Procedures

OBJECTIVEnSimulation may be a useful tool for training in endovascular procedures. The aim of this study was to evaluate the effect of endovascular repair of abdominal aortic aneurysms (EVAR) simulation in boosting trainees learning curve.nnnDESIGNnTen vascular surgery residents were recruited and divided in 2 groups (Trainee Group and Control group). At a first session (t0), each resident performed 2 simulated EVAR procedures using an endovascular simulator. After 2 weeks, each participant simulated other 2 EVAR procedures in a final session (t1). In the period between t0 and t1, each resident in the Trainee Group performed 6 simulated EVAR procedures, whereas the Control Group did not perform any other simulation. Both quantitative and qualitative performance evaluations were performed at t0 and t1. Quantitative evaluation from simulator metrics included total procedural time (TP), total fluoroscopy time (TF), time for contralateral gate cannulation (TG), and contrast medium volume (CM) injected. Qualitative evaluation was based on a Likert scale used to calculate a total performance score referred to skills involving major EVAR procedural steps.nnnRESULTSnAll residents in the Trainee Group significantly reduced TP (48 ± 12 vs 32 ± 8 minutes, t0 vs t1, p < 0.05), TF (18 ± 7 vs 11 ± 6 minutes, p < 0.05), and CM used over time (121 ± 37 vs 85 ± 26ml, p < 0.05), but not TG (5 ± 5 vs 3 ± 4 minutes, p = 0.284). In the Control Group metrics did not change significantly in any field (TP = 55 ± 11 vs 46 ± 10 minutes; TF = 25 ± 9 vs 21 ± 4 minutes; CM = 132 ± 51 vs 102 ± 42ml; TG = 6 ± 4 vs 8 ± 5 minutes, all p > 0.05). The average Trainee Group qualitative total performance score improved significantly (p < 0.05) after rehearsal sessions when compared with the Control Group.nnnCONCLUSIONnSimulation is an effective method to improve competence of vascular surgery residents with EVAR procedures.

Endovascular Management of Para-prosthetic Aortocaval Fistula: Case Report and Systematic Review of the Literature

The aim of this article is to report a case of asymptomatic para-anastomotic aortocaval fistula (ACF) treated by endovascular aortic repair, and to review data of the literature on arteriovenous fistulae secondary to abdominal aortic surgery. A 78-year-old male complained of worsening pain in the right lower limb since 2xa0months. He presented a history of right femoropopliteal bypass for peripheral arterial occlusive disease and elective surgical treatment for a non-ruptured infrarenal aortic aneurysm (Dacron tube graft). Duplex ultrasound revealed an occlusion of the right common femoral artery and bypass graft. The digital subtraction angiography confirmed these findings and showed progression of the contrast medium from the aorta to the inferior vena cava at aortic carrefour level, suggestive of ACF. An abdomen/pelvis computed tomography angiogram (CTA) confirmed the arteriovenous communication at distal anastomosis of the aortoaortic Dacron graft. An urgent endovascular placement of AFX™ (Endologix, Inc., Irvine, CA) aorto-biiliac stent graft was performed, associated with endarterectomy of the right common and deep femoral artery. The postoperative course was regular without complications. The 5-day and 1-month CTA showed complete exclusion of the ACF. A systematic review of the literature was also performed regarding ACF secondary to aortic surgery.

Early and mid-term results in the endovascular treatment of popliteal aneurysms with the multilayer flow modulator

Background The endovascular approach became an alternative to open surgical treatment of popliteal artery aneurysm over the last few years. Heparin-bonded stent-grafts have been employed for endovascular popliteal artery aneurysm repair, showing good and stable results. Only few reports about the use of multilayer flow modulator are available in literature, providing small patient series and short follow-up. The aim of this study is to report the outcomes of patients with popliteal artery aneurysm treated with the multilayer flow modulator in three Italian centres. Methods We retrospectively analysed a series of both symptomatic and asymptomatic patients with popliteal artery aneurysm treated with the multilayer flow modulator from 2009 to 2015. Follow-up was undertaken with clinical and contrast-enhanced ultrasound examinations at 1, 6 and 12 months, and yearly thereafter. Computed tomography angiography was performed in selected cases. Primary endpoints were aneurysm sac thrombosis; freedom from sac enlargement and primary, primary-assisted and secondary patency during follow-up. Secondary endpoints were technical success, collateral vessels patency, limb salvage and aneurysm-related complications. Results Twenty-three consecutive patients (19 males, age 72u2009±u200911) with 25 popliteal artery aneurysms (mean diameter 23 mmu2009±u20091, 3 symptomatic patients) were treated with 40 multilayer flow modulators during the period of the study. Median follow-up was 22.6u2009±u200916.7 months. Complete aneurysm thrombosis occurred in 92.9% of cases (23/25 cases) at 18 months. Freedom from sac enlargement was 100% (25/25 cases) with 17 cases of aneurysm sac shrinkage (68%). At 1, 6, 12 and 24 months, estimated primary patency was 95.7%, 87.3%, 77% and 70.1%, respectively. At the same intervals, primary-assisted patency was 95.7%, 91.3%, 86% and 86%, respectively, and secondary patency was 100%, 95.7%, 90.3% and 90.3%, respectively. Technical success was 100%. The collateral vessels patency was 72.4%. Limb salvage was 91.4% at 24-month follow-up. One multilayer flow modulator fracture was reported in an asymptomatic patient. Conclusions Multilayer flow modulator seems a feasible and safe solution for endovascular treatment of popliteal artery aneurysms in selected patients.

Late open conversions after endovascular abdominal aneurysm repair in an urgent setting

Objectives We report a multicenter experience of urgent late open conversion (LOC), with the goal of identifying the mode of presentation, technical aspects, and outcomes of this cohort of patients. Methods A retrospective analysis of endovascular aneurysm repair (EVAR) requiring LOC (>30 days after implantation) from 1996 to 2016 in six vascular centers was performed. Patients with aneurysm rupture or other conditions requiring urgent surgery (<24 hours) were included. Patient demographics, time interval between EVAR and LOC, endograft characteristics, previous attempts at endovascular correction, indications, operative technique, 30‐day mortality and morbidity, and long‐term survival were analyzed. Results There were 42 patients (88.1% men; mean age, 75.8 ± 9.0 years) included. Among the 42 explanted grafts, 33 were bifurcated, 1 tube, 6 aortouni‐iliac, and 2 side‐branch devices. Suprarenal fixation was present in 78.6%. Twelve patients (28.6%) underwent endovascular reintervention before LOC. Indications for urgent LOC were aneurysm rupture in 24 of the 42 cases (57.1%), endograft infection in 11 (26.2%), endoleak associated with aneurysm growth and pain in 6 (14.3%), and recurrent endograft thrombosis in 2 (4.8%). The proximal aortic cross‐clamping site was infrarenal in 38.1% of cases, suprarenal in 19.1%, and supraceliac in 42.9%. Complete removal of the endograft was performed in 32 patients (76.2%) and partial removal in 10 (proximal preservation in 7 of 10). Reconstructions were performed with Dacron grafts in 33 of the 42 cases, cryopreserved arterial allografts in 5, and endograft removal associated with prosthetic axillobifemoral bypass in 4. The 30‐day mortality was 23.8%; hemorrhagic shock was an independent risk factor of early mortality (odds ratio, 10.5; 95% confidence interval, 1.5‐73.7; P = .018). During a mean follow‐up of 23.9 ± 36.0 months, two late aneurysm‐related deaths occurred. The estimated 1‐ and 5‐year survival rates were 62.1% and 46.1%, respectively. Conclusions Urgent LOC after EVAR are associated with high postoperative mortality rates and poor long‐term survival. Further studies are necessary to define the timing and the best treatment option for failing EVAR.

IP043. Predictors of Survival in Malignant Aortic Tumors

Objective: Malignant aortic tumors are exceedingly rare. For that reason, no case series have been published so far in the literature, and a comprehensive review of clinical and therapeutic aspects is lacking. The aim of this study was to analyze all known cases of malignant aortic tumors and to identify predictors of patients’ survival. Methods: All patients with a diagnosis of aortic tumor treated in a single center together with all case reports and reviews available in the literature (through a specific PubMed search with keywords such as malignant and aorta or aortic tumor or sarcoma or angiosarcoma) were analyzed. Tumor primary location, clinical presentation, histologic features, and treatment choice were all examined. Survival at 1 year, 2 years, and 5 years and the possible preoperative and operative predictors of outcome were evaluated by Kaplan-Meier analysis with log-rank test. Results: In addition to the 5 cases treated in our center, 218 other cases of malignant aortic tumor have been reported in the literature from 1873 to 2017. Overall, the mean age of the patients was 60.1 6 11.9 years, and the male to female ratio was 1.59:1. The mean overall survival from diagnosis was 13.6 6 7.7 months; 1-, 3-, and 5-year survival rates were 35.2% 6 3.7%, 10.9% 6 2.6%, and 6.1% 6 2.2%, respectively (Fig). Chronic hypertension (P 1⁄4 .03), fever (P 1⁄4 .03), back pain (P 1⁄4 .01), asthenia (P 1⁄4 .04), and signs of peripheral embolization (P 1⁄4 .007) were significant predictors of patients’ poor outcome. Histologic subtypes had different impacts on

Surgical Treatment of a High-Flow Femoro-Femoral Arteriovenous Fistula in an Intravenous Drug Abuser

BACKGROUNDnWe report the surgical treatment of a high-flow femoro-femoral arteriovenous fistula (AVF), a rare complication of intravenous drug abuse.nnnMETHODSnA 36-year-old woman with history of intravenous heroin and cocaine abuse presented with right lower limb edema, inguinal bruit, and heart failure. Duplex ultrasound examination (DUS) and computed tomography angiography showed a large, high-flow AVF involving the common femoral vein and the superficial femoral artery, which is associated with thrombosis of the great saphenous vein and an important inflammation in the right groin, without active bleeding. Under general anesthesia, the patient underwent open surgical repair of the AVF through a right-groin cutdown. The 3-cm-long AVF was repaired with the interposition of a bovine pericardium patch that is sewn from inside the femoral vein through a longitudinal venotomy with a continuous 5-0 polypropylene suture.nnnRESULTSnThe venotomy was repaired with a 5-0 polypropylene running suture. No perioperative or postoperative complications were recorded. The inguinal bruit resolved, the arteries recovered good pulsatility, and the lower limb edema promptly reduced. A 6-month DUS confirmed the patency of the femoral arteries and veins and the absence of AVF or infection signs in the right groin.nnnCONCLUSIONSnSurgical repair of femoro-femoral AVF in drug abusers by biologic patch interposition is a challenging, but feasible, and effective technique with encouraging midterm results in terms of patency and resistance to infections.

Significance and Risk Factors for Intraprosthetic Mural Thrombus in Abdominal Aortic Endografts: A Systematic Review and Meta-analysis

BACKGROUNDnThe detection of intraprosthetic thrombus (IPT) deposits is a common finding during follow-up for endovascular abdominal aneurysm repair (EVAR); however, its clinical significance is still debated. The aim of this study was to determine if IPT represents a risk factor for thromboembolic events (TEs; endograft or limb thrombosis, or distal embolization) after EVAR.nnnMETHODSnA systematic review of English literature was undertaken until November 2017. Studies providing 2-group comparison (patients with IPT development on postoperative computed tomography angiography versus patients without IPT) with extractable outcome data (TE related to IPT and/or risk factors for IPT development) were included. Meta-analysis was performed when comparative data were given in 2 or more articles.nnnRESULTSnFive single-center studies (808 patients) were analyzed. IPT detection at any time during follow-up occurred in 20.8% (168/808) of patients. Extractable data for postoperative TE were available in 4 studies (613 patients): on comparative meta-analysis, IPT was not significantly associated with TE occurrence during follow-up (odds ratio 2.25, 95% confidence interval [CI] 0.50-10.1; Pxa0=xa00.29). IPT is generally detected during the first year after EVAR (maximum reported median: 12xa0months, range: 1.2-23). Polyester graft material (odds ratio 2.34, 95% CI 1.53-3.58; Pxa0<xa00.001) and aorto-uni-iliac configuration of the endograft (odds ratio 3.27, 95% CI 1.66-6.44; Pxa0=xa00.001) were confirmed as risk factors for IPT formation on meta-analysis. The literature systematic review suggests that IPT formation may be also associated with long main bodies and large necks.nnnCONCLUSIONSnIPT detection on postoperative computed tomography angiography was not significantly associated with the occurrence of TE over time. The aorto-uni-iliac configuration and the use of polyester fabric for endografts were confirmed as risk factors for IPT development.

Outcomes of Duplex-Guided Paramalleolar and Inframalleolar Bypass in Patients with Critical Limb Ischemia

BACKGROUNDnThe aim of the study was to evaluate the outcomes of duplex ultrasonography (DUS)-guided autologous vein bypass to paramalleolar (distal third of tibial arteries and peroneal artery) and inframalleolar arteries (dorsalis pedis, common plantar, medial, and lateral plantar arteries) in patients with critical limb ischemia (CLI) and extensive tibial artery disease Trans-Atlantic Inter-Society Consensus D.nnnMETHODSnBetween January 2007 and October 2016, all paramalleolar or inframalleolar bypasses performed in patients with CLI, planned only on the basis of DUS, were collected and analyzed retrospectively. DUS evaluation included arterial disease extension, inflow and outflow arteries diameter, outflow vessels resistance, and autologous veins quality. Patients demographics and clinical characteristics were assessed. Tissue loss was graded according to Texas University Wound Classification (TWC). Follow-up included periodic clinical and DUS examinations. Primary end points were technical success (TS) (patent bypass with distal anastomosis performed on the Duplex-selected runoff artery, without stenosis >30% and in line flow with the inframalleolar arteries at completion angiography and without hemodynamic bypass stenosis at postoperative DUS) and bypass patency (primary [PP], assisted [AP], and secondary [SP]). Secondary end points were perioperative and follow-up patient survival (PS), limb salvage (LS), and amputation-free survival (AFS). Descriptive statistics and Kaplan-Meier analysis were performed. Univariate and Multivariate Cox analyses were used to define risk factors.nnnRESULTSnSeventy-four bypasses in 73 patients with CLI (Rutherford 5-6 93.2%, TWC stage III in 63.5% and grade D in 48.6%) were performed in the study period (January 2007-October 2016). diabetes mellitus, coronary artery disease, and kidney disease were present in 67.6%, 60.8%, and 37.8% patients, respectively. Distal anastomosis was performed at the paramalleolar and inframalleolar arteries in 47.3% and 52.7%, respectively. Only autologous veins were used as conduit. TS was 98.6%. At 1-month, PP, AP, SP, PS, LS, and AFS were 87.8%, 91.9%, 93.2%, 95.9%, 94.6%, and 90.5%, respectively. The mean follow-up was 33.7xa0months; at 1-year, PP, AP, SP, PS, LS, and AFS were 54.4%, 71.4%, 75.1%, 89.9%, 84.3%, and 79.1%, respectively, and at 3-year, 42.3%, 63%, 66%, 67.5%, 80.6%, and 61%, respectively. At univariate and multivariate analyses, arterial hypertension was protective for PP (Pxa0=xa00.035) while insulin-dependent diabetes was a negative predictor (Pxa0=xa00.01); insulin-dependent diabetes was a negative predictor of LS (Pxa0=xa00.002); TWC grade D was a negative predictor of AP (Pxa0=xa00.047) and SP (Pxa0=xa00.013). Age (Pxa0<xa00.001) and major amputation (Pxa0=xa00.014) resulted as negative predictors of PS.nnnCONCLUSIONSnBypass of the Duplex-selected paramalleolar and inframalleolar arteries in CLI has high TS and high rate of perioperative and late LS. Duplex evaluation and planning in CLI patients with extensive tibial arteries disease is associated with efficacy of surgical revascularization and high LS rates.