Claudio Bianchini Massoni

Follow-up outcomes of hybrid procedures for thoracoabdominal aortic pathologies with special focus on graft patency and late mortality

OBJECTIVE The purpose of this study was to analyze midterm results of bypass patency and overall and aortic-related mortality rates of hybrid aortic procedures for thoracoabdominal aortic pathologies. METHODS A retrospective study was performed considering prospectively collected data in two centers. From January 2001 to December 2012, 45 patients (33 men; mean age, 67.8 ± 7.6 years) received hybrid aortic procedures for thoracoabdominal aortic diseases (31 atherosclerotic aneurysms, 7 chronic expanding type B aortic dissections, 2 penetrating aortic ulcers, and 5 pseudoaneurysms), corresponding to 155 revascularized visceral abdominal arteries. Elective/emergency and staged/simultaneous approaches were 31 of 14 and 28 of 17, respectively. Patient demographics, clinical risk factors, and aortic morphological and procedural data were collected. End points were technical success, 30-day morbidity, reintervention and mortality, bypass graft patency, freedom from reintervention, and overall and aortic-related mortality during midterm follow-up. Mean follow-up was 2.2 ± 2.4 years. RESULTS Technical success was achieved in 86.6% (39/45) of patients. Thirty-day morbidity rate was 60% (paraplegia/paraparesis: 13.3%, stroke: 6.7%, renal failure: 31.3%, permanent dialysis: 4.4%). Thirty-day freedom from reintervention rates were 67.1% and 78.5%, respectively. Thirty-day occlusion of revascularized visceral vessels occurred in 11 (7.1%, 11/155) target arteries. In-hospital mortality rate was 24.4%. Primary graft patency after 1, 2, and 4 years was 89.7%, 85.3%, and 79%, respectively. Bypass thrombosis or stenosis developed in nine (6.8%, 9/132) vessels during follow-up. Of these, three patients required reintervention and one died. Freedom from reintervention rates after 1, 2, and 4 years were 45.6%, 45.6%, and 34.2%, respectively. Overall and aortic-related mortality rates after 1, 2, and 4 years were 32.6%, 41.4%, and 45.3% and 9.1%, 13.9%, and 13.9%, respectively. CONCLUSIONS A hybrid procedure for thoracoabdominal aortic pathologies in high-risk patient is feasible but carries a significant rate of early and midterm reintervention and death. Long-term surveillance of the visceral bypass is necessary because one-third of the patients will have bypass-related complications.

Fenestrated and Branched Endograft after Previous Aortic Repair

BACKGROUND Para-anastomotic aneurysms (P-AAA) and proximal aortic aneurysmal degeneration after previous aortic open repair (OR) or endovascular repair (EVAR) are challenging clinical scenarios. OR is technically demanding, and standard EVAR could be impossible due to the absence of proximal landing zone. The aim of the study is to report midterm results of fenestrated and branched endografts (FB-EVAR) to treat proximal aortic lesions after previous aortic repair. METHODS Since 2010, patients that underwent FB-EVAR after previous aortic repair were prospectively enrolled. Clinical or morphologic or intraoperative or postoperative data were collected and retrospectively analyzed. Primary end points were technical success and clinical success. Secondary end points were procedure-related events (endoleaks, target visceral vessels occlusion, mortality), midterm survival and freedom from FB-EVAR-related reinterventions. RESULTS Twenty patients (Male: 98%, age: 75 ± 6 years, American Society of Anesthesiologists [ASA] ≥ III: 100%) were enrolled. Fifteen patients (75%) underwent previous aortic OR and 5 (25%) standard EVAR. The mean time since the previous treatment was 12 ± 10 years. Present aortic lesions included thoracoabdominal aneurysms 12 (60%) and juxtarenal and pararenal aneurysms 8 (40%). The mean aortic aneurysm diameter was 67 ± 15 mm. All patients were at high risk for OR and had anatomies precluding standard EVAR. Seventy-two visceral vessels (renal arteries: 34, superior mesenteric artery: 20, celiac trunk: 18) were targeted: 49 fenestrations, 19 branches, and 4 scallops. An FB-EVAR tube and trimodular endograft was planned in 17 and 3 cases, respectively. Technical success was 95%; operative target vessel perfusion was 98.5%. Thirty-day mortality was 0%. Clinical success was 80% because there was a transient renal function worsening in 4 patients (>30% of baseline). One distal type I endoleak was detected and treated at 1-month. The mean follow-up was 15 ± 11 months. There were not proximal type I endoleaks, target visceral vessel occlusions, or aneurismal-related mortality. Survival at 1 year was 85 ± 5%. One late FEVAR-related reintervention occurred. CONCLUSIONS According to the reported data, FB-EVAR for treating P-AAA or proximal aneurysmal degeneration after previous aortic OR/EVAR in high-risk patients is a safe and/or effective solution.

Adjunctive stenting of endograft limbs during endovascular treatment of infrarenal aortic and iliac aneurysms according to 3-projection completion angiography.

Purpose To evaluate the role of 3-projection completion angiography in defining endograft limb stenosis after endovascular aneurysm repair (EVAR) and to determine the role of adjunctive stenting in reducing the risk of endograft limb occlusion. Methods In our center, stent-graft limb dilation was routinely done after endograft deployment in patients with preoperatively identified severe iliac axis angulation to reduce the incidence of limb stenosis. Completion angiography was then routinely performed in anteroposterior (AP) and 45° right and left oblique projections to identify perioperative endograft limb stenosis after the stiff guidewires were removed. Adjunctive stenting was used in iliac limbs with postangioplasty residual stenosis >50%. From January 2005 to November 2010, 302 EVAR patients (296 men; mean age 74.25±7.04 years, range 53–90) with 589 stent-graft limbs (aortomonoiliac stent-graft in 15 patients) who had a minimum 6 months of follow-up and a nonstenotic aortic bifurcation were selected for this study. Patient demographics, clinical risk factors, iliac anatomical features, procedure data, and limb patency were analyzed. Primary endpoints were the incidence of limb stenosis >50% and any associated risk factors; the secondary endpoint was the primary patency of stent-graft limbs with adjunctive stenting. Results On 3-projection completion angiography, 40 (6.8%) limbs presented limb stenosis and were treated with adjunctive stenting; in only 28 (70%) of these cases was the >50% limb stenosis evident on the AP view. According to the degree of preoperative iliac angulation, limb stenosis occurred in mild (<60°), moderate (60°–89°), and severe (≥90°) angulations in 14 (4.6%), 9 (5.6%), and 17 (13.4%) cases, respectively; positive predictors for limb stenosis were severe iliac artery angulation [vs. moderate (p=0.02) and mild (p=0.001)] and stent-graft limb diameter <16 mm (p=0.02). In the adjunctive stenting group, the mean follow-up was 16.1 months; no graft occlusion, graft erosion, or restenosis was seen during follow-up (100% primary patency at 12 and 24 months). Conclusion Three-projection completion angiography is crucial to identifying limb stenosis, for which adjunctive stenting appears to ensure primary patency in midterm follow-up. Preoperative iliac artery angulation and small endograft limb diameter are positive prognostic factors for limb stenosis >50%.

Lower limb malperfusion in type B aortic dissection: a systematic review

BACKGROUND Lower limb malperfusion (LLM) syndrome occurs in up to 40% of complicated type B aortic dissections (TBAD) and in up to 71% of TBAD with malperfusion syndrome. This syndrome is associated with higher 30-day mortality. The aim of this systematic review was to provide clinical and procedural data of patients with LLM syndrome secondary to TBAD. METHODS The PubMed database was systematically searched from January 2000 to June 2014 for English-language publications reporting on demographic data of patients with LLM secondary to TBAD. RESULTS A total of 29 papers were included (10 original articles and 19 case reports), reporting on a total of 138 patients (mean age =58±12 years; male =87%). Lower limb complications developed in acute and chronic TBAD in 134 (97%) and 4 (3%) cases, respectively. LLM presented with acute limb ischemia in 120 (87%) patients. Bilateral clinical presentation occurred in 56% (40/72) of cases. LLM was the only clinically detected malperfusion in 52% of cases (44/84). In 40% (35/84) and 25% (21/84) of cases, LLM was clinically associated with renal and visceral malperfusion, respectively. Radiological imaging showed renal, celiac trunk and superior mesenteric artery involvement in 53% (47/88), 31% (27/88) and 34% (30/88) of cases, respectively. Medical, surgical and endovascular treatments were performed in 22 (16%), 51 (37%) and 65 (47%) patients, respectively. Thirty-day morbidity was 31% (13/42) and 46% (6/13) following surgical and endovascular treatment, respectively. Thirty-day mortality was 14% (5/36) and 8% (2/26) following surgical and endovascular treatment, respectively. CONCLUSIONS LLM syndrome secondary to TBAD usually developed during the acute phase and, in most cases, presented with acute limb ischemia. Bilateral clinical presentation occurred in more than half of cases. Renal and visceral malperfusion were frequently associated with lower limb flow reduction but LLM was the only clinically detected malperfusion in more than half of patients. Surgical fenestration was burdened with significant complication rates and 30-day mortality. Endovascular procedures showed lower mortality but complication rates remained high.

Impact of kidney ischemic lesions on renal function after fenestrated endovascular repair

OBJECTIVE Fenestrated endovascular aortic repair (fEVAR) is being used increasingly in the treatment of complex aortic aneurysms; however, this procedure can be associated with visceral and renal complications. Because the causes of possible renal function (RF) impairment have not been fully examined yet, we conducted a study to investigate whether there are risk factors associate with renal ischemic lesions (RILs) and if they influence RF in patients treated for complex aortic aneurysm with fEVAR. METHODS We evaluated the clinical, anatomic, and technical characteristics of consecutive patients treated with fEVAR from 2008 to 2014. RIL were identified by postoperative computed tomography angiography and the volume of renal parenchyma involved quantified. A decrease in RF (>30% glomerular filtration rate reduction) was evaluated at discharge, and at the 6- and 12-month follow-ups. RESULTS Among 53 patients, we analyzed 38 (72%) juxta/pararenal and 15 (28%) thoracoabdominal aortic aneurysms (33 [64%] with ≥3 fenestrations) and 102 renal arteries. Fifteen patients (30%) showed RIL, which was caused by accessory renal artery (ARA) coverage in 6 cases (38%), distal embolism in 6 (38%), renal artery thrombosis in 2 (18%), and iatrogenic embolization for intraoperative bleeding during fEVAR in 1 (6%). The volume of renal parenchyma involved was less than 25% in 10 (67%) and 25% to 50% in 5 (33%) cases. In no cases was more than 50% renal volume affected. On multivariate analysis, RIL predictors were the presence of ARA (odds ratio [OR], 8.00; 95% confidence interval [CI], 1.16-54.89; P = .03) and extensive thrombosis of the pararenal aorta (OR, 39.93; 95% CI, 3.36-474.23; P = .003). At discharge, chronic renal failure (CRF; OR, 4.80; 95% CI, 1.27-18.09; P = .01), diabetes (OR, 8.44; 95% CI, 1.33-53.51; P = .01), and extensive thrombosis of the pararenal aorta (OR, 5.50; 95% CI, 1.32-29.92; P = .01) were significantly associated with worsening RF. RIL, independent from volume, did not influence the postoperative RF. At 6 months and 1-year, preoperative CRF and perioperative declines in RF were identified as the only risk factors for worsening RF. CONCLUSIONS RIL is a common fEVAR complication and is primarily owing to ARA coverage and aortic thrombus embolization. However, RIL does not influence RF, which is predicted by preoperative CRF, diabetes, and extensive aortic thrombus.

Endovascular Treatment of Inflammatory Infrarenal Aortic Aneurysms

Objectives: The aim of this study was to evaluate short- and midterm outcomes of endovascular aneurysm repair in patients with inflammatory abdominal aortic aneurysm (IAAA) focusing on changes in perianeurysmal inflammation and hydronephrosis. Methods: A retrospective study was performed considering data prospectively gathered from 1998 to 2013 in 3 centers. Patient demographics, preoperative clinical characteristics, clinical presentation, preoperative imaging measurements, procedural, and postoperative data were collected. Main outcome was to define evolution of periaortic fibrosis and hydronephrosis at computed tomography angiography (CTA) during follow-up. Results: A total of 22 patients (male n = 20; mean age 70.9 years ± 9.3) were included (mean AAA diameter: 58 mm ± 11, symptomatic: 50%, ruptured: 9.1%). Hydroureteronephrosis was preoperatively diagnosed by CTA in 6 (27.3%) cases. Median clinical follow-up was 2.2 years (range 0.1-14.5). Nine patients died during follow-up. At 1, 2, 4, and 6 years, overall survival was 85.4%, 74.3%, 56.6%, and 49.5%, respectively. Among these 13 patients with CTA follow-up, the mean AAA diameter was 56.2 mm ± 15.5, and progression of sac diameter was detected in 1 (7.7%) patient. Median maximum thickness of perianeurysmal inflammation was 5 mm (range 2-11) and decreased/remained unchanged in 92.3% of patients. Regression of hydroureteronephrosis occurred in 3 of 5 patients available for follow-up. There were no cases of de novo hydroureteronephrosis. Conclusion: Endovascular treatment of IAAA has comparable short-term outcomes with non-IAAA. During midterm follow-up, aneurysm sac progression is rare, and perianeurysmal fibrosis decreases or remains unchanged in most cases. Hydronephrosis regression can occur in some but not all instances and thus warrants close surveillance.

A Comparison of Two Surgical Techniques for the Second Stage of Brachiobasilic Arteriovenous Fistula Creation

Two-stage transposed brachiobasilic arteriovenous fistula is a common procedure after brachiobasilic fistula (BBF) creation. Different techniques can be used for basilic vein transposition but few comparative literature reports are available. The aim of our study was to compare two different techniques for basilic vein transposition. The first maintains the BBF anastomosis and the basilic vein is placed in a subcutaneous pocket (BBAVF). The second transects the basilic vein at the BBF anastomosis and tunnels it superficially, with a new BBF in the brachial artery (BBAVFTn). From 2009 to 2014, all patients who underwent basilic vein superficialization were treated by one of the two techniques, recorded in a dedicated database and retrospectively reviewed. The surgeon chose the technique on the basis of personal preference. The two techniques were compared in terms of perioperative complications, length of hospital stay, time of cannulation, ease of cannulation, and long-term patency. Eighty patients were included in the study: 40 (50%) BBAVF and 40 (50%) BBAVFTn. Length of hospital stay was similar in the two groups (median [interquartile range-IQR] 3(2) [BBAVF] vs. 2(1) [BBAVFTn], P = 0.52, respectively). BBAVFTn was associated with a lower hematoma incidence (1/40 [2.5%] vs. 15/40 [37.5%], P = 0.01), shorter first cannulation time (median IQR: 11(10) vs. 23(8) days, P = 0.01) and easier cannulation compared with BBAVF (32/40 [80%] vs. 15/40 [37.5%], P < 0.001). Median (IQR) follow-up was 16(7) months. No statistical differences in terms of primary and assisted primary patency were found in BBAVFTn vs. BBAVF (at 24 months 91(5) vs. 71(7), P = 0.21 and 93(6) vs. 78(8), P = 0.33, respectively). Patients who underwent BBAVFTn surgery showed fewer surgical complications, better dialytic performance, and easier cannulation compared with those submitted to BBAVF.

A systematic review of treatment modalities and outcomes of type Ib endoleak after endovascular abdominal aneurysm repair

Objectives To collect specific literature on type Ib endoleak after aorto-iliac endografting for abdominal aortic aneurysm, reporting data on diagnosis, treatment, and follow-up results. Methods Publications about type Ib endoleak after aorto-iliac endografting for abdominal aortic or iliac aneurysm were searched in PubMed, Web of Science, and Scopus. Considered studies were in English and published until 3 November 2016. Research methods and reporting were performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Inclusion criteria were: (1) reporting on abdominal aortic or iliac aneurysm as primary diagnosis; (2) reporting on distal endoleak after aorto-iliac endografting. Patient data, data on endovascular treatment, endoleak, reintervention, and follow-up were collected by two independent authors. Results Included studies were 11 (five original articles, six case reports), corresponding to 29 patients and 30 type Ib endoleak. Excluding missing data (2/30, 6.7%), type Ib endoleak was treated intra-operatively, within six months and after six months in six cases (21.4%), eight cases (28.6%), and fourteen cases (50%), respectively. Treatment of type Ib endoleak was endovascular in 27 cases (90%) (7 embolizations + extender cuffs, 10 extender cuffs, 8 embolizations without extender cuff, 1 Palmaz stenting and 1 iliac branched endograft), hybrid in 1 case (3.3%) and surgical in 2 cases (6.6%). Buttock claudication occurred in two cases (6.7%). One-month mortality was 3.4% (2/29) without events due to type Ib endoleak. In 14 cases (46.7%), median follow-up was six months (interquartile range: 2.75–14; range: 0.75–53). Type Ib endoleak persisted or reappeared in three cases (10%), all after endovascular treatment. Two of these (2/3, 66.7%) needed endovascular reintervention. No death during follow-up was reported. Conclusions Few specific data are available in literature about type Ib endoleak after aorto-iliac endografting for abdominal aortic aneurysm. About 50% of type Ib endoleak occurred after six months from the endovascular abdominal aneurysm repair procedure. Treatment is mainly endovascular and distal endograft extension is the main and effective treatment. Buttock claudication is the most frequent complication in case of exclusion of internal iliac artery. Persistent type Ib endoleak is possible, and adjunctive endovascular procedures are necessary.

Infrarenal inferior vena cava injury after blunt trauma

A 23-year-old male was struck by a truck whilst riding his bicycle. He was intubated at the scene, where his blood pressure was borderline stable (90/50 mmHg) and transiently responded to fluid resuscitation. A total body computed tomography angiogram (CTA) showed a small laceration (arrow) of the infra-renal inferior vena cava (IVC), with a large pericaval hematoma and compression of the lumen (Panel A1). Maximum intensity projection (MIP) displayed contrast outside the IVC with dilation of caudal venal districts and low enhancement of the cranial segment (Panel A2). Hemodynamics remained stable with massive transfusions after resuscitation; the patient was admitted into the intensive care unit. Three days later, CTA showed persistent but decreased contrast effusion (arrow) outside the cava (Panel B1) and cavography illustrated a pericaval pseudoaneurysm (Panel B2–3). Hemodynamic parameters remained sufficiently stable (95/60 mmHg). Two weeks after the injury, a new CTA scan documented the disappearance (arrow) of the pericaval pseudoaneurysm and reabsorption of the hematoma (Panel C1–3: axial slice, tridimensional reconstruction, maximum intensity projection, respectively) (See video for a timeline of the imaging follow-up and patient’s clinical evolution). IVC injuries are a rare and potentially life-threatening event with a 50% mortality rate upon hospital arrival.1 Blunt trauma is an infrequent cause of IVC lesions (0-16%)2 with high in-hospital mortality (70%).3 Peri/ infra-renal segments are rarely involved.3 Initial volume repletion and aggressive resuscitation are first-line treatment. In stable patients, CTA is the gold standard imaging modality to assess hematoma location and size as well as vena cava contour.4 In cases of hemodynamic instability, open surgery is the treatment of choice, while endovascular treatment is reported to control venous bleeding from inaccessible segments (retrohepatic IVC).5 Clinical observation and monitoring is a reasonable approach in patients who are hemodynamically stable.6 Close follow-up with appropriate imaging is mandatory and multiple CTAs are usually performed. Spontaneous self-tamponade after IVC injury is reported in 50%1 of

IP009. Intraoperative Contrast-Enhanced Ultrasound for Early Diagnosis and Treatment of Endoleaks During Endovascular Abdominal Aortic Aneurysm Repair∗

Objective: The objective of this study was to evaluate the feasibility of intraoperative contrast-enhanced ultrasound (CEUS) to detect and to treat endoleaks (EL) during endovascular aneurysm repair (EVAR). Methods: Patients undergoing elective EVAR from January to December 2017 were consecutively enrolled. After endograft deployment, two completion angiography studies (2CAs) with orthogonal Carm angulation (anteroposterior and 90-degree left anterior oblique) were routinely performed. Intraoperative CEUS was performed in sterile conditions on the surgical field before guidewire removal. Presence and type of EL at the 2CAs and CEUS were evaluated and prospectively collected. CEUS was performed by a vascular surgeon blinded to the findings of the 2CAs. The primary end point was the agreement between the 2CAs and CEUS for detection of any EL and type II EL (Cohen k). The