Claudio Fitta

Strategies of endoleak management following endoluminal treatment of abdominal aortic aneurysms in 95 patients: how, when and why

PurposeThis study reviews, on the basis of our experience, the indications and options for treating endoleaks (EL) after endovascular repair of abdominal aortic aneurysms (AAA) by endografting.Materials and methodsNinety-five patients (M/F =92/3; mean age at time of operation 70.7±7.8 years) who underwent endovascular repair of infrarenal AAA between April 1997 and October 2004 were considered. All images of 420 pre-and postoperative computed tomography (CT) studies were reviewed.ResultsA total of 37 EL occurred in 33/95 patients (34.7%), four of whom had two EL of different types. Eighteen EL were treated, 16 by endoluminal treatment. Six EL were type I: 2 were treated by percutaneous transluminal angioplasty (PTA) and 4 by cuff deployment (2 proximal cuffs and 2 distal cuffs). Eight EL were type II: 2 were treated by PTA, 2 by cuff deployment, 1 by transcatheter coil embolisation of the inferior mesenteric artery, two by thrombin injection in the aneurysm sac and one underwent surgical conversion during an attempt to treat a concomitant type I EL. Finally, 2 EL were type III: 1 was treated by PTA and 1 by cuff deployment. Endovascular treatment was successful in 12/16 cases (75%), whereas 3/16 cases (18.8%) were converted to open surgery, and 1 patient died of AAA rupture the day after endovascular repair.ConclusionsEL is the most common complication after endovascular repair of AAA. In type I and type III EL, treatment is mandatory, whereas in type II (and type V) EL, treatment is indicated in the presence of AAA enlargement. Type IV EL generally disappear spontaneously. Endovascular repair is feasible and can be performed with different techniques according to EL aetiology, but it is not always decisive, and in some cases surgical conversion is required.RiassuntoObiettivoRevisionare, in base alla nostra esperienza, le indicazioni e le opzioni terapeutiche per il trattamento degli endoleak (EL) successivi al trattamento endovascolare degli aneurismi dell’aorta addominale (AAA) mediante endoprotesi (EP).Materiali e metodiSono stati considerati retrospettivamente 95 pazienti consecutivi (M/F=92/3; età media al momento dell’impianto 70,7±7,8 anni) sottoposti nel periodo aprile 1997-ottobre 2004 ad impianto di EP per esclusione di AAA infrarenale. Sono state revisionate le immagini di 420 esami TC eseguiti sia in fase preoperatoria che postoperatoria.RisultatiIn 33/95 (34,7%) dei pazienti si sono verificati complessivamente 37 EL, essendovi stati 4 pazienti con 2 EL di tipo diverso. Fra questi, 18 EL hanno richiesto trattamento, di cui 16 per via endovascolare. Sei EL erano di tipo I: 2 sono stati trattati con PTA e 4 con il posizionamento di cuffie (2 prossimali e 2 distali). Otto EL erano di tipo II: 2 sono stati trattati con PTA, 2 con il posizionamento di una cuffia iliaca, 1 con embolizzazione transcatetere dell’arteria mesenterica inferiore, 2 con iniezione di trombina all’interno della sacca aneurismatica e in un caso, associato anche ad EL di tipo I, nel tentativo di trattamento di quest’ultimo, si è ricorsi a conversione chirurgica. Infine 2 EL erano di tipo III: 1 è stato trattato con PTA e 1 con il posizionamento di una cuffia iliaca. Il tasso di successo tecnico è stato del 75% (12/16 EL), essendovi stata necessità di conversione chirurgica in 3/16 casi (18,8%) ed essendo un paziente deceduto il giorno successivo al trattamento endovascolare per rottura dell’AAA.ConclusioniL’EL rappresenta una delle complicanze più frequenti dopo trattamento endovascolare di AAA. Sono sempre candidati al trattamento gli EL graft-correlati (tipi I e III), mentre gli EL di tipo II (e tipo V) devono essere trattati solo se associati a crescita dimensionale dell’AAA. Gli EL di tipo IV solitamente si risolvono con regressione spontanea. Il trattamento endovascolare è possibile secondo diverse modalità in base all’eziologia dell’EL, ma non sempre è risolutivo e talvolta è necessario ricorrere alla conversione chirurgica.

Abdominal Aortic Aneurysm with Coexistent Horseshoe Kidney

Surgical repair of an abdominal aortic aneurysm (AAA) concomitant with a horseshoe kidney (HSK) may be technically demanding because of the complex anomalies of the kidney and of its collecting system and arteries, the greater risk of HSK-related complications, and the often unexpected intraoperative finding of HSK itself. We reviewed a database of more than 500 patients with AAA observed in our surgical department from 1994 to the time of writing. Five patients had AAA concomitant with HSK. Two of these patients did not undergo surgery because of the small dimension of the aneurysm or because of their poor health. The other three underwent successful repair of AAA with different techniques; namely, an aortobifemoral bypass via a thoracoabdominal retroperitoneal incision in one, a straight graft via an emergency median laparotomy in one, and an endovascular repair followed by open surgery 4 years later for endotension in one. Abnormal minor renal arteries were deliberately occluded and only one of these caused a minor renal infarct, but without functional impairment. These data and a review of the literature indicate that HSK should not preclude repair of coexistent AAA, as imaging procedures provide the information necessary to plan the best approach for each patient. Up-to-date surgical procedures, a posteriori retroperitoneal approach or endovascular repair, and deliberate occlusion of the minor renal arteries appear feasible and safe as they avoid most of the anatomical problems and provide results equivalent to those of uncomplicated aortic surgery.

Tracheoinnominate fistula in a Duchenne muscular dystrophy patient: Successful management with an endovascular stent *

Tracheoinnominate fistula is a rare but often fatal complication occurring in Duchenne Muscular Dystrophy (DMD) patients with long-term tracheostomy. We report a 16-year-old boy with DMD who developed a fistula causing massive haemorrhage 26 months after tracheostomy. Due to the high risk of perioperative complications, a minimally invasive technique with placement of an endovascular stent grafting the innominate artery was performed. The patient was successfully managed and recovered uneventfully. We believe that endovascular repair of tracheoinnominate fistula by stent grafting may be the treatment of choice in severely compromised patients and that clinicians who treat tracheostomised DMD patients should be familiar with this management strategy.

Morphological and functional modifications of the aneurysm-endograft complex following endoluminal treatment of abdominal aortic aneurysms

Purpose.The aim of the study was to evaluate quantitatively the main morphological changes of the abdominal aortic aneurysm (AAA)-endograft (EG) complex following endovascular repair of infrarenal AAA and to evaluate the functional consequences of these changes in terms of rate of complications (endoleaks and thrombosis). We also assessed whether these morphological and functional changes were related to the size of the AAA and to the type of EG used.Materials and methods.Eighty-five patients (M/F=82/3; mean age at time of operation 70.5±3.5 years, range 49.9–89.6 years) who underwent endovascular treatment of infrarenal AAA between April 1997 and October 2004 with a follow-up of at least 1 month were considered. All images of 408 preoperative and postoperative computed tomography (CT) studies were reviewed. Statistical analysis was performed with log-rank test on the 85 patients grouped according to AAA diameter <50 mm or ≤50 mm, and on 75 patients grouped according to EG device used (AneuRx, Talent or Excluder).Results.Morphological and dimensional changes involved the diameter (six cases) and length (14 cases) of AAA proximal neck, diameter (36 cases) and length (51 cases) of the aneurysm sac and shape of the stent-graft (47 cases). The prevalence of endoleaks was 37.6% whereas endoluminal thrombosis was observed in 27.1% of patients. AAA growth was significantly correlated (p=0.002) with the preprocedural diameter of the aneurysm sac whereas shrinkage was significantly correlated (p=0.0005) with the EG used.Conclusions.AAA growth was correlated with the diameter of the aneurysm sac while shrinkage was correlated with the EG used. During follow-up after endovascular repair, patients require careful evaluation of the morphological and dimensional features of the AAA and EG to promptly identify any changes that can anticipate major complications and even conversion to conventional surgery.

Treatment options in fibromuscular dysplasia of the renal artery: when percutaneous transluminal angioplasty is at high risk?

Treatment options in fibromuscular dysplasia of the renal artery: when percutaneous transluminal angioplasty is at high risk?

Hypoxic antiblastic stop-flow limb perfusion: a novel treatment for in transit melanoma metastases. Clinical outcome and pharmacokinetic findings

BackgroundHypoxic antiblastic stop-flow perfusion (SFP) has recently been proposed as a therapeutic option for patients with locally advanced tumors. The present paper reports on the clinical and pharmacological results of our prospective study of limb SFP for the treatment of in transit melanoma metastases. Patients and methodsTwenty-three patients with limb-sited melanoma metastases were treated with melphalan (10 mg/l) based pelvic (n=11, group A) or femoral (n=12, group B) SFP under hypoxic conditions. Systemic and locoregional toxicity, tumor response rate, and local progression–free survival were analyzed. Melphalan concentrations were measured in the perfusate and systemic circulation during SFP, and after 30-minute hemofiltration. Perfusate-to-plasma leakage was assessed using a scintigraphic method. ResultsNo postoperative deaths occurred. Mild locoregional toxicity was observed in 5 patients (18%), and systemic toxicity was mild to severe in 8 patients (30%), the incidence being higher in group A. Tumor response rate (complete + partial response) and time to local disease progression were significantly different in group A and B (9% vs 58% and 7 vs 13 months, respectively). The pharmacokinetic study showed that pelvic SFP was associated with a higher leakage rate and a lower area under the curve ratio than femoral SFP (44% vs 31% and 5.6 vs 9.8, respectively). ConclusionsLimb SFP is a feasible and relatively simple procedure, and is associated with an acceptable toxicity rate. Tumor response rates are encouraging and strictly depend upon drug leakage. Further efforts should be made to exploit the potential anti-tumor activity of this novel locoregional drug delivery system.