Carmelo Ricci

A Complex Thoracoabdominal Aneurysm in a Loeys-Dietz Patient: An Open, Hybrid, Anatomic Repair

We report the successful treatment of a life-threatening thoracoabdominal aneurysm in a young patient affected by type I Loeys-Dietz syndrome. To overcome anatomic and surgical difficulties, we used an original strategy and a specially designed surgical tool. The clinical and technical aspects of this approach are presented.

Midterm results of proximal aneurysm sealing with the ovation stent-graft according to On-vs off-label use

Purpose: To compare the use of the Ovation stent-graft according to the ≥7-mm neck length specified by the original instructions for use (IFU) vs those treated off-label (OL) for necks <7 mm long. Methods: A multicenter retrospective registry (TriVascular Ovation Italian Study) database of all patients who underwent endovascular aneurysm repair with the Ovation endograft at 13 centers in Italy was interrogated to identify patients with a minimum computed tomography (CT) follow-up of 24 months, retrieving records on 89 patients (mean age 76.4±2.4 years; 84 men) with a mean follow-up of 32 months (range 24–50). Standard CT scans (preoperative, 1-month postoperative, and latest follow-up) were reviewed by an independent core laboratory for morphological changes. For analysis, patients were stratified into 2 groups based on proximal neck length ≥7 mm (IFU group, n=57) or <7 mm (OL group, n=32). Outcome measures included freedom from type Ia endoleak, any device-related reintervention, migration, and neck enlargement (>2 mm). Results: At 3 years, there was no aneurysm-related death, rupture, stent-graft migration, or neck enlargement. There were no differences in terms of freedom from type Ia endoleak (98.2% IFU vs 96.8% OL, p=0.6; hazard ratio [HR] 0.55, 95% CI 0.02 to 9.71 or freedom from any device-related reintervention (92.8% IFU vs 96.4% OL, p=0.4; HR 2.42, 95% CI 0.34 to 12.99). In the sealing zone, the mean change in diameters was −0.05±0.8 mm in the IFU group and −0.1±0.5 mm in the OL group. Conclusion: Use of the Ovation stent-graft in patients with neck length <7 mm achieved midterm outcomes similar to patients with ≥7-mm-long necks. These midterm data show that the use of the Ovation system for the treatment of infrarenal abdominal aortic aneurysm is not restricted by the conventional measurement of aortic neck length, affirming the recent Food and Drug Administration–approved changes to the IFU.

JAG Tearing Technique with Radiofrequency Guide Wire for Aortic Fenestration in Thoracic Endovascular Aneurysm Repair

An innovative approach, the JAG tearing technique, was performed during thoracic endovascular aneurysm repair in a patient with previous surgical replacement of the ascending aorta with a residual uncomplicated type B aortic dissection who developed an aneurysm of the descending thoracic aorta with its lumen divided in two parts by an intimal flap. The proximal landing zone was suitable to place a thoracic stent graft. The distal landing zone was created by cutting the intimal flap in the distal third of the descending thoracic aorta with a radiofrequency guide wire and intravascular ultrasound catheter.

[Combined radiologic-urologic procedure for the placement of ureteral stent in a case of bilateral iatrogenic ureteral lesion].

Introduction Iatrogenic ureteral lesions are well-known complications of abdominal and pelvic surgery. A combined radiologic-urologic approach might be necessary to repair these lesions. Materials and Methods A 69-year-old woman underwent bilateral hysteroannessectomy for endometrial cancer. She then became anuric. A CT scan showed multiple urinomas caused by bilateral ureteral lesions. The continuity of the two urinary tracts was restored using ureteral stents in a combined urologic and radiologic procedure. Results The patient improved clinically and the renal function returned within normal limits. Conclusions The combined antegrade-retrograde approach is an effective technique to solve iatrogenic ureteral lesions.

Case Report: Aortic Valve Replacement After JARVIK 2000 Left Ventricular Assist Device Implantation in Long-Time Survivor With Severe Aortic Valve Regurgitation

BACKGROUND There are limited clinical records in the literature regarding aortic valve replacement in left ventricular assist device (L-VAD) patients. Previously we had two cases of severe aortic valve regurgitation in patients with L-VAD support treated with Corvalve prosthesis insertion and Amplatzer closure procedure. Both patients died a few days after the procedure from complications not related to the procedure itself. PATIENT HISTORY The patient was a male with previous coronary artery bypass graft surgery in 2001 that was complicated with postischemic dilated cardiomyopathy with severe heart failure (ejection fraction [EF], 20%). Cardiac resynchronization therapy was biventricular-pacemaker and cardiac defibrillator implantation in 2009 for recurrent ventricular arrhythmia. L-VAD implantation (Jarvik 2000) with graft apposition in descending thoracic aorta through left thoracotomy access and retro-auricolar cable was performed in October 2013. In 2015 the patient underwent surgical aortic valve replacement with bioprothesis due to progressive worsening of the aortic valve regurgitation. The Jarvik 2000 outflow was occluded with vascular ball occluder inserted via right axillary artery under fluoroscopy before CEC installation. The recovery was without major complications. DISCUSSION Long-time survivors with Jarvik 2000 are increasing in number and such late complication is expected to become a main future issue. Our previous experience with the interventional approach was delusive. Due to the fatal consequences in similar patients with nonsurgical approaches, we opted for surgical aortic valve replacement. At the moment, the international literature does not describe safe approaches regarding aortic valve replacement in patients with Jarvik 2000 L-VAD. This case shows that surgical valve replacement could be managed with success according to the described specific technique.

First World Report of Internal Power Cable Repair in Left Ventricular Assist Device Jarvik 2000: Case Report

BACKGROUND There are limited clinical reports concerning internal power cable fixing in left ventricular assist device (L-VAD) patients. Actually there are no reports in the literature about Jarvik 2000 internal cable repair. We show the first description of a technique for surgical reparation of such a fatal complication. PATIENT HISTORY The patient was a 62-year-old woman who had L-VAD implantation (Jarvik 2000) with outflow graft apposition in descending thoracic aorta through left thoracotomy access, in 2009. She arrived urgently on January 25, 2014 for Jarvik 2000 dysfunction correlated with head movements. The neck X-rays revealed the rupture of one of the nine power cables located inside the neck and the damaging of two more cables nearby to be ruptured. On the same day she got pump failure due to the final interruption of the remaining two cables, we were obliged to install femoro-femoral extracorporeal membrane oxygenation (ECMO) assistance, to repair the power cables, approaching them through a pacemaker extension cable. The L-VAD outflow was occluded with vascular ball occluder inserted via right axillary artery under fluoroscopy before ECMO installation. At the end the ECMO assistance was interrupted and the Jarvik 2000 was turned back on. The patient was dismissed from the hospital 12 days after the procedure. DISCUSSION At the moment the international literature is poor regarding this issue. This case provides evidence that in emergency conditions ECMO assistance is mandatory and a hybrid surgical and radiological approach could help to repair the damage in safe conditions.

External jugular vein spontaneous aneurysm, diagnosis and treatment with video

True and false aneurysms of veins are very rare conditions and only few cases have been described in the literature. We present a case of a 56-year-old female with personal history of primary arterial hypertension and connective tissue disease. Ultrasound of the neck showed a saccular, compressible, hypoechoic structure that appeared to have a direct communication with the left external jugular vein lumen. The venous aneurysm was removed and the histopathology of the mass showed a grossly dilated vein, with continuous aspects of the entire 3 layer of the venous wall, classifying it as a venous aneurysm.

New endovascular strategy to overcome anatomical constraints when dealing with aortoiliac aneurysms

Involvement of the iliac arteries with an abdominal aortic aneurysm (AAA) is seen in 20% to 30% of AAA patients. Treatment options have been dramatically changed over the last 10 years. At first, the only endovascular option was embolization of the internal iliac artery (IIA) using coils or plugs to extend the iliac limbs of the aortic stent-graft past the IIA. In a significant number of patients, however, IIA embolization may cause chronic symptoms, such as buttock claudication and sexual dysfunction, whether transient or permanent. The most successful endovascular options to preserve IIA flow have been branched stent-grafts and the bell-bottom technique. Implantation of branched stentgrafts has been shown to be feasible and safe, with good long-term outcome, even if the device is significantly more expensive. The bell-bottom technique was developed to approach IIAs with diameters between 18 and 24 mm, which precludes its use in aneurysms with larger distal landing zones. In 2011, Lobato et al. described the sandwich technique for aortoiliac aneurysms, which included 5 steps: (1) bifurcated stentgraft main body insertion through an ipsilateral femoral approach and positioned such that the distal end of the iliac limb is 1 cm above the IIA origin; (2) catheterization of the ipsilateral IIA through a left brachial access; (3) placement of a covered self-expanding stent 2 cm inside the IIA with a 6-cm overlap into the iliac limb, followed by positioning of an iliac limb extension 1 cm below the covered stent’s proximal end; (4) modeling of the iliac limb stent-grafts using a latex balloon and dilation of the covered stent with an angioplasty balloon; and (5) deployment of the contralateral iliac limb. As performed by the authors, the sandwich technique was favorably accepted by other investigators, and midterm results seem promising. In our institution, we have used this technique in 12 patients to date (7 described in a previous article). Cannulating the IIA from the brachial artery and advancing an endograft from the upper extremity proved uncomplicated. Sealing the commissural angles was successful, as oversizing the limb grafts in relation to the diameter of the main graft produces a tight apposition of the components. The technique satisfactorily recanalized the IIA and was free from intraprocedural complications. Now with a mean follow-up of 20 months (range 6–47), we have seen no endoleak in any patient. The iliac aneurysm sac diameter has shrunk (range 1–15 mm) in