Daniela Mazzaccaro

Outcomes of urgent carotid endarterectomy for stable and unstable acute neurologic deficits

OBJECTIVE The aim of the study was to assess the outcomes of carotid endarterectomy (CEA) performed in an urgent setting on acutely symptomatic patients selected through a very simple protocol. METHODS From January 2002 to January 2012, 193 symptomatic patients underwent CEA. Of these, 90 presented with acute symptoms, and after a congruous carotid stenosis was identified, underwent urgent operations (group 1): 27 patients had transient ischemic attack (group 1A), 52 patients had mild to moderate stroke (group 1B), and 11 patients had stroke in evolution (group 1C). The remaining 103 patients with a nonrecent neurologic deficit were treated by elective surgery in the same period (group 2). End points were 30-day neurologic morbidity and mortality. RESULTS The median delay of urgent CEA (U-CEA) from deficit onset was 48 hours (interquartile range, 13-117 hours). Groups 1 and 2 were comparable in demographics. Acute patients showed a higher rate of stroke at presentation (70% vs 37%; P = .001) and of history of coronary artery disease (30% vs 13.5%; P = .007). Acute patients sustained six postoperative strokes (6.6%). Neurologic outcomes were correlated to clinical presentation: no strokes occurred in group 1A patients, and 5.8% group 1B patients and 27.3% group 1C patients had postoperative stroke (P < .01). Postoperative mortality was 4.4% for U-CEA: one fatal myocardial infarction, one intracranial hemorrhage, and two thromboembolic strokes. Elective patients sustained four postoperative strokes (3.9%), with one death (0.9%) as a consequence of hyperperfusion cerebral edema. U-CEAs performed ≤48 hours from symptom onset had a lower postoperative stroke rate than those performed >48 hours (4.4% vs 8.8%; P = .3). Among patients presenting with a stroke (group 1B), the National Institutes of Health Stroke Scale (NIHSS) assessment at discharge showed improvement in 79% (although only 25% had ≥4 points in reduction), stability in 17%, and deterioration in 4%. Patients with moderate stroke were slightly better in NIHSS improvement than those with mild stroke (median NIHSS variation at discharge, -3 vs -1; P = .001). CONCLUSIONS Our results with U-CEA confirm that this population has a higher risk profile compared with elective surgery. The type of acute presentation is correlated with perioperative risk. U-CEA was safe when performed on patients presenting with transient ischemic attack. An acceptable complication rate was achieved for patients with minor to moderate strokes. The poorest outcomes occurred in patients presenting with stroke in evolution: U-CEA in these patients should be offered with extreme caution, although we are aware that a conservative treatment may not grant a better prognosis.

Seat belt injuries of the abdominal aorta in adults--case report and literature review

Blunt abdominal trauma with major vascular involvement is found to be rare. Although few series have been reported in the literature, the true incidence of blunt abdominal aortic injury is unknown. Different modalities of blunt trauma may occur among civilians with steering wheel and seat belt injury secondary to motor vehicle accident the most frequent. Mechanical forces produce variable patterns of injury; therefore, the onset of signs and symptoms can be different. Dissection and thrombosis of the abdominal aorta have been frequently described among seat-belted adult patients with major vascular involvement. The associated abdominal viscus and/or vertebral lesions must always be taken into account. Prompt diagnosis allows adequate surgical treatment. We present the case of a 66-year-old woman, restrained front passenger involved in a motor vehicle collision, who had small bowel transection, vertebral fractures, and aortic partial occlusion below inferior mesenteric artery with bilateral iliac artery involvement. Along with the case reported, the purpose of this study is to highlight and compare features and management of the previous cases described in the English literature.

Endovascular treatment of iatrogenic axillary artery pseudoaneurysm under echographic control: A case report

AimBrief case report of the treatment of a large axillary artery pseudoaneurysm after a pacemaker using a left brachial cutdown and a retrograde delivery of a covered stent using ultrasound and fluoroscopic guidance. The patients renal function precluded the use of contrast materials.Case ReportA 77 years old man presenting with acute renal failure and haemoglobin decrease arrived with an expanding pseudoaneurysm of the left axillary artery from a pacemaker placement. Considering the site of the lesion and patients comorbidities, under echographic control, a Hemobahn® stent-graft was placed; fluoroscopy assisted manipulation of guidewires and sheaths into the aortic arch. The procedure was successfully ended without any complications. At 8 months the stent graft was still patent.ConclusionUltrasound guidance may represent an alternative for pseudo-aneurysm exclusion without any use of contrast medium, especially in those patient where lesions are easily detectable using ultrasonography and when comorbidities contraindicate aggressive surgical or angiographic approach.

Immediate and Late Open Conversion after Ovation Endograft

The risk of intraoperative open conversion during endovascular aortic repair (EVAR) still remains a main issue, albeit in a small percentage of cases. Open conversion can be extremely demanding and risky in relation to the type of the stent graft implanted and can be somehow challenging even for the most experienced vascular surgeons. We discuss a case of immediate conversion and 1 case of late conversion in patients previously treated with EVAR using the Ovation stent graft. The design of the endograft and its proximal sealing allowed the partial preservation of the graft and its use for proximal and distal anastomosis with a Dacron graft in both presented cases.

Comparison of posterior and medial approaches for popliteal artery aneurysms

BACKGROUND Long-term results of the posterior approach (PA) for the treatment of popliteal artery aneurysms are lacking in the literature. We reviewed our experience during a 13-year period in patients with popliteal artery aneurysms, comparing those treated through a PA with those operated on through a standard medial approach (MA). METHODS Clinical data of all patients treated between February 1998 and October 2011 were retrospectively reviewed and outcomes analyzed. The Kaplan-Meier method was used to estimate survival, and χ(2), Wilcoxon, and log-rank tests were used for analysis. RESULTS A total of 77 aneurysms were treated in 65 patients (64 men). Mean age was 68 years (range, 48-96 years). Thirty-six aneurysms were asymptomatic (47%). Mean sac diameter was 2.8 ± 1 cm. A PA was used in 43 PAAs (55%) and an MA in 34. The PA and MA patients differed significantly in age (median being older), smoking history (more frequent in PA), and renal insufficiency and cerebrovascular disease (higher for MA). In 42 cases the aneurysm was symptomatic (54.5%) for chronic limb ischemia, with intermittent claudication in 18 patients, acute ischemia in 17, blue toe syndrome in 3, compression on adjacent structures in 3, and rupture with severe acute pain in 1. All PA repairs consisted of aneurysmectomy with an interposition graft with end-to-end anastomoses; among MA repairs, 22 interposition grafts and 12 bypasses were performed. A polytetrafluoroethylene graft was used in 54 cases. Five patients had an early thrombosis (two PA and three MA). No perioperative deaths occurred. Two patients sustained a permanent (PA) and a temporary (MA) peroneal nerve lesion. There were no early amputations. The median in-hospital stay was longer for MA (10 days) than for PA (7 days; P = .02). Median follow-up was 58.8 months (range, 5 days-166 months). Nine patients died during follow-up of unrelated causes. The 5-year primary and secondary patency rates were 59.6% ± 8.6% and 96.5% ± 3.4%, respectively, for PA, and 65.1% ± 11.1% and 79.4% ± 9.7%, respectively, for MA (P = .53 for primary patency rate and P = .22 for secondary patency rate). Limb salvage was 100% at 5 years and 93.3% ± 6.4% at 10 years for PA and 91.1% ± 6.3% at both time points for MA (P = .28). CONCLUSIONS PA and MA both achieved satisfactory results in primary and secondary patency rates, as well as limb salvage, during long-term follow-up. The differences between the two groups were small and not statistically significant. PA was burdened by similar postoperative nerve and wound complications compared with MA. The in-hospital stay after PA was significantly lower.

Hybrid endovascular treatment of an aortic root and thoracoabdominal aneurysm in a high-risk patient with Marfan syndrome.

This report describes the hybrid endovascular treatment of an aortic root dilatation and a thoracoabdominal aneurysm in a high-risk patient with Marfan syndrome. A 50-year-old male, in hemodialysis for polycystic kidney and polycystic liver, was referred to our department for aortic root dilatation of 5 cm and a 6.3-cm thoracoabdominal aneurysm . He already underwent surgical repair of abdominal aortic aneurysm 10 years ago, complicated by pseudoaneurysm of the proximal anastomosis that had been treated in another center, with an endoprosthesis. The patient underwent aortic root replacement, aortic valve sparing operation, and rerouting of the superior mesenteric artery and celiac trunk to the ascending aorta. The thoracoabdominal aneurysm was excluded with an endoprosthesis few days after the surgical step. The 12-month computed tomography scan confirmed the complete exclusion of the thoracoabdominal aneurysm.

Ruptured hemiarch and descending thoracic aorta aneurysm: hybrid treatment

Ruptured aortic arch aneurysm is a life threatening disease. Surgical repair has an high perioperative mortality rate and totally endovascular treatment is a challenge. Hybrid repair has been proposed as a valuable approach. We report the case of a patient with a contained rupture of aortic arch aneurysm. We treated him with a debranching of supraortic vessels with carotid-carotid and carotid-subclavian bypass and deployment of two enodgrafts in two different times. We consider hybrid treatment for arch and hemiarch a feasible option for aortic arch aneurysms in non emergent and in an emergency setting with an improvement in perioperative morbidity and mortality.

Tips About the Cordis INCRAFT Endograft

BACKGROUND Recently, the new Cordis INCRAFT abdominal aortic aneurysm (AAA) Stent-Graft System ultra low-profile device has been introduced in the clinical practice of endovascular aortic repair (EVAR) for the treatment of infrarenal AAAs (iAAAs). In our operative unit, it has been used since November 2014. We report our initial experience with the use of this novel device. We further discuss some technical aspects about the use of the endograft. METHODS Data of all patients undergoing elective EVAR in our Division of Vascular Surgery using the Cordis INCRAFT AAA Stent-Graft System from November 2014 till now were retrospectively collected in a database and outcomes reviewed. Follow-up data were analyzed to evaluate primary success, survival, complications, and device-related events. Statistical analysis was performed using JMP(®) 5.1.2 (SAS Institute Inc., Cary, NC). Continuous variables are reported as mean ± standard deviation, and categorical variables are presented as n (%). RESULTS From November 2014 till now in our institution, a total of 10 patients (7 male; mean age, 76.3 years old; range, 65-87 years) underwent elective exclusion of an iAAA with a challenge iliac anatomy (minimum access vessel, 6.7 mm) using Cordis INCRAFT endoprosthesis. There were 9 AAA and a left common iliac artery aneurysm 50 mm in diameter, involving the internal iliac artery. Primary success was achieved in 90% as 1 patient presented an immediate type Ia endoleak which was resolved by the placement of a proximal aortic cuff. There was 1 intraoperative acute leg ischemia requiring a left popliteal Fogarty thrombectomy. Three patients (30%) presented a postimplantation syndrome. No other complications occurred neither during in-hospital stay (mean, 3.4 days; range, 2-4 days) nor during follow-up. CONCLUSIONS In our experience, the Cordis INCRAFT AAA System was a safe and effective device. Our reflections about technical aspects of the use of this device will probably find their answer when further studies will report shared experiences and results about using this type of endograft.

Long-Term Results of Carotid Artery Stenting in Patients 80 Years and Older

INTRODUCTION We report our experience about carotid artery stenting (CAS) in patients 80 years and older. MATERIALS AND METHODS Out of 582 patients who underwent CAS at our institution from January 1999 to June 2010, 102 patients (group A) were 80 years or older. The clinical data of these patients were retrospectively reviewed, outcomes analyzed, and compared with those of younger patients who underwent CAS during the same period (group B). RESULTS Outcomes of group B were similar to those of group A, both at 30 days and at long term. Male gender, symptoms, and not using an embolic protection device were related to long-term complications in both groups. Occurrence of bradycardia/asystole during CAS was a risk factor for long-term myocardial infarction for group A only. CONCLUSIONS CAS can be safely performed in patients 80 years or older, with results that compare favorably to those of younger patients.

IP073. Are Endoleaks Type Ia Predictable

patients (23%) were clustered in group 1 and 47 (77%) in group 2. Both groups were homogeneous for clinical characteristics and preoperative morphological risk factors. There were no differences in preoperative median TV, THV, %VR, EgV, and number of implanted coils between groups. Patients in group 1 had a significantly wider EFV (59 6 13 cc vs 42 6 27 cc; P 1⁄4 .009) and lower CCoil (0.09 6 0.03 vs 0.18 6 0.21) than patients of group 2. ELIIp was significantly related to the presence of EFV >46 cc (86% group 1 vs 42% group 2; P 1⁄4 .006) and CCoil <0.17 coil/cc (100% group 1 vs 68% group 2; P 1⁄4 .014). Conclusions: AAA sac coil embolization is effective to reduce incidence of ELIIp in selected high-risk patients, and the CCoil may be considered to determine the necessary number of coils to obtain a complete AAA sac thrombosis.