Danilo Menna

Preliminary Results from a National Enquiry of Infection in Abdominal Aortic Endovascular Repair (Registry of Infection in EVAR - R.I.EVAR)

BACKGROUND To preliminary report on epidemiology, risk factors, diagnosis, treatments, and outcomes in a multicenter series of patients treated for endovascular aortic repair (EVAR) infection and detected by an Italian National enquiry. METHODS From June 2012, 26 cases of abdominal aortic endograft infection were collected by a National Enquiry and recorded in the Italian National Registry of Infection in EVAR. Cases collected were available for patients submitted to EVAR implantation from January 2004 to June 2013. RESULTS Mean time from EVAR treatment to infection diagnosis was 20.5 ± 20.3 months (range, 1-72). In 6 cases (23.1%), an aortoenteric fistula (AEF) was detected. Positive microbiologic cultures were found in 20 patients (76.9%). More than 1 infectious agent was found in 6 cases (19.2%). EVAR infection treatment was conservative in 4 cases, endovascular in 2. Endograft excision was performed in 10 cases by conventional treatment (aortic stump + extra-anatomic bypass) and in 10 cases by in situ reconstruction (cryopreserved allograft or rifampin-soaked silver Dacron graft). A 30-day mortality was 38.4% (10 of 26 cases), 3 patients died from 2 to 24 months after infection treatment, accounting for a mean time from infection treatment to death of 1.25 ± 0.62 months. Mortality rates were 50% in all treatment groups. In those survived (13 of 26 cases) recurrence-free follow-up after infection treatment was 27.9 ± 22.4 months (range, 2-74). Four patients with AEF died in the first month after treatment (66.6%). Suprarenal endografts required supraceliac aortic cross-clamping for removal. Supraceliac cross-clamping was burdened by higher mortality rates than infrarenal cross-clamping (71.4% vs. 30.7%). CONCLUSIONS EVAR infection diagnosis is burdened by extremely high mortality rates. Prospective registries could help monitoring outcomes in EVAR infection patients and, possibly, developing new surveillance protocols in patients at high risk of recurrence.

Factors Influencing Outcome after Open Surgical Repair of Juxtarenal Abdominal Aortic Aneurysms

The purpose of this study was to seek factors predicting outcome after open surgical repair of juxtarenal abdominal aortic aneurysms (AAAs). From a series of 733 patients treated for AAAs, 92 patients underwent elective conventional open repair with suprarenal clamping. We assessed postoperative cardiorespiratory and renal morbidity and mortality and survival at 1, 3, and 5 years. One patient (1.1%) died after an acute myocardial infarction. Postoperative complications including myocardial infarction and renal failure arose in 22 patients (23.9%). Significant predicting factors of renal failure were a preoperative creatinine clearance ≤ 40 mL/min (p = .03) and female sex (p = .004). Kaplan-Meier survival analysis showed an overall survival rate of 98.9% at 1 year and 88.6% at 3 and 5 years. In patients carefully selected by preoperative imaging criteria to undergo open juxtarenal AAA repair, appropriate intraoperative management guarantees a good immediate postoperative outcome.

Infective etiology affects outcomes of late open conversion after failed endovascular aneurysm repair

Purpose: To retrospectively review all patients undergoing late open conversion (LOC) after endovascular aneurysm repair (EVAR) in order to identify any clinical or technical predictors of poor outcome. Methods: Twenty-six consecutive patients (24 men; mean age 74.7±8.3 years) underwent LOC between June 2006 and April 2013 at our institution. The mean interval from index EVAR to LOC was 40.4±29.2 months (range 5–93 months). The indication for LOC was endoleak in 14 (54%) patients and infection in 12 (46%): 2 (8%) patients with endoleak had a ruptured aneurysm and 6 (23%) patients with infection had a recurrent secondary aortoesophageal fistula (sAEF). Results: In all 12 cases of infection and in 12 of 14 endoleaks, the entire endograft was explanted. A rifampin-soaked Dacron silver graft was implanted in all patients with infection. Patients with any infection and with recurrent AEF required more blood units than patients with endoleak (6.40 vs. 1.86, p=0.045; 6.76 vs. 1.86, p=0.0036, respectively). Compared with endoleak, the duration of conversions in the setting of infection (274 vs. 316 minutes, p=0.42) and recurrent sAEF (274 vs. 396 minutes, p=0.021) was longer. All patients with recurrent sAEF died at a mean 3.0±2.5 days after LOC from proximal anastomosis disruption and hemorrhagic shock (n=2), myocardial infarction (n=2), acute stroke (n=1), or persistent sepsis (n=1). Perioperative mortality was significantly higher in patients with endograft infection (6/12, p=0.002) and in cases of supraceliac cross-clamping (4/6, p=0.003). The association of infection with supraceliac cross-clamping was a strong predictor for perioperative mortality (p<0.001). Conclusion: In our experience, endograft infection led to greater perioperative mortality after LOC. Recurrent aortoenteric fistula in association with supraceliac cross-clamping is a strong predictor of poor outcome. Patients surviving the perioperative period may have good chances of long-term survival.

Ten Years' Experience in Endovascular Repair of Popliteal Artery Aneurysm Using the Viabahn Endoprosthesis: A Report from Two Italian Vascular Centers

BACKGROUND Although rare, popliteal artery aneurysms (PAAs) are the most commonly observed peripheral arterial aneurysms. Surgical repair is considered the gold standard, even if with debated results. The aim of our study is to evaluate the outcome of endovascular treatment of PAAs using the Viabahn peripheral endograft (W. L. Gore and Associates, Inc., Flagstaff, AZ) in 2 high-volume Italian centers. METHODS All consecutive PAA patients treated by endovascular procedures between January 2004 and December 2013 were retrospectively reviewed. True atherosclerotic aneurysms, symptomatic and asymptomatic, were included in the analysis. All patients were treated by high-skilled vascular surgeons. The outcome measures were graft thrombosis, reintervention rate, and limb salvage at early and long-term follow-up. RESULTS Fifty-three PAAs were treated. Patients were more frequently male (98.1%) with a mean age of 73.6 ± 7.8 years. Twelve patients (22.6%) were symptomatic and in 8 of them a local fibrinolysis was required before definitive surgery. Mean PAA diameter was 30.9 ± 10.9 mm (range 17-60). Fifty-two patients (98.1%) had at least 1 patent runoff vessel. Technical success was achieved in all patients. Overall, 80 stent grafts were deployed and in 21 patients (39.6%) more than 1 stent graft was deployed. In-hospital mortality rate and 30-day reinterventions were null. At a mean follow-up of 37.4 ± 29.3 months, primary patency, secondary patency, and limb salvage were respectively 73.6%, 92.4%, and 100%. CONCLUSION In our limited, retrospective experience, the endovascular treatment of PAA by Viabahn stent graft allowed satisfactory technical and clinical results even at long-term follow-up.

Mandibular subluxation as an adjunct in very distal carotid arterial reconstruction: incidence of peripheral and cerebral neurologic sequelae in a single-center experience.

BACKGROUND The location of the carotid bifurcation and a very distal extension of internal carotid atherosclerotic disease may challenge vascular surgeons performing carotid endarterectomy (CEA) by increasing technical difficulty and possibly the incidence of cranial nerve damage or palsies. The objective of the present study is to report on the safety of CEA with mandibular subluxation (MS) and to compare results of CEA in 2 groups of patients treated by standard CEA or by MS-CEA according to rates of major neurologic complications, death, and the occurrence of postoperative peripheral nerve palsy. METHODS Between July 2000 and June 2012, 1,357 CEAs were performed. MS was additionally used in 43 patients. Only patients with primary atherosclerotic internal carotid artery (ICA) lesions in the 2 groups (38 in the MS-CEA group and 1,289 in the standard CEA group) were considered for comparative analysis. RESULTS MS-CEA patients were more frequently male (P = 0.03), presented more frequently with symptomatic lesions (P = 0.007), longer lesions (P = 0.01), and had common ICA bypass implantation (P = 0.02). Mean follow-up was 68.75 ± 37.87 months (range: 1-144 months). No perioperative neurologic mortality and no prolonged discomfort related to MS was recorded. The overall neurologic morbidity rate (major stroke/minor stroke/transient ischemic attach) was comparable in the 2 groups (P = 0.78). The overall immediate peripheral nerve injury rate was 7.89% in the MS-CEA group and 5.27% in the standard CEA group (P = 0.73). Three cases of permanent dysphonia in the standard CEA group (0.23%) and 1 case of dysphagia in the MS-CEA group (2.63%) were reported at follow-up (P = 0.24). CONCLUSIONS MS-CEA can be a very useful technical adjunct for high-located carotid bifurcations or challenging carotid lesions, with an overall risk comparable to that of standard CEA.

Retrograde Type B Aortic Dissection as a Complication of Standard Endovascular Aortic Repair

Endovascular repair (EVAR) for abdominal aortic aneurysms (AAAs) is becoming the standard of practice in most vascular centers, even if some concerns remain about the occurrence of early and long-term failure and reintervention. A rare but potential catastrophic event is represented by retrograde type B aortic dissection (RTBAD). We report 2 cases of RTBAD after 425 standard EVARs performed in our institution. Both patients were treated for AAA without perioperative complication, and in both the patients, the presence of a preexisting disease of the thoracic aortic wall (ulcerated plaque in 1 case and aortic ectasia in the other) may have played an important role in the rapid evolution toward an early onset of the dissection. Only few cases of type B dissection after EVAR have been reported in literature, and the etiology of this complication remains uncertain. For the first time, our experience highlights the possible etiologic role of preexisting lesions of the thoracic aorta. In these cases, the only possible strategy may be to carefully study the entire aorta before an EVAR procedure, eventually switching the indication to an open surgical repair or carrying out a more aggressive management, treating the defects of the thoracic aorta.

Endovascular treatment of a small infrarenal abdominal aortic aneurysm causing duodenal obstruction: Case report and literature review.

Duodenal obstruction caused by abdominal aortic aneurysm was first described by Osler in 1905 and is named “aortoduodenal syndrome.” This condition has always been treated by open surgical repair. We report the first case of aortoduodenal syndrome successfully treated by endovascular aneurysm repair. A 74-year-old male patient referred to our hospital complaining postprandial vomit, reporting a consistent weight loss in the latest weeks. Enhanced computed tomography scans showed a small saccular abdominal aortic aneurysm compressing duodenum and inferior vena cava without any other evident pathological finding. As the patient underwent a successful endovascular treatment of the abdominal aortic aneurysm, symptoms immediately resolved so that he started back to feed and progressively gained body weight. Despite aortoduodenal syndrome is generally caused by large abdominal aortic aneurysm, this condition has to be suspected also in case of small abdominal aortic aneurysm. Differently from what has been reported in literature, endovascular aneurysm repair could be effective in the treatment of aortoduodenal syndrome.

An atypical case of contrast-induced encephalopathy after carotid artery stenting

Neurotoxicity caused by contrast agents is a rare and less known complication of percutaneous carotid and coronary interventions. Radiological signs, such as cortical enhancement and brain edema, are of utmost importance in diagnosis. A 70-year-old female patient underwent left carotid artery stenting to treat a post-traumatic asymptomatic carotid dissection. Three hours after intervention, a mild aphasia developed with no brain alteration on diffusion-weighted magnetic resonance imaging (DW-MRI). Twelve hours after intervention, symptoms worsened but a new DW-MRI scan showed no pathological findings. Since a contrast-induced encephalopathy was diagnosed, fluid administration was raised to 2 mL/kg/h and the neurological status progressively improved. In the following three days, neurological deficit slowly regressed. Two weeks after intervention, aphasia had disappeared and a further cerebral DW-MRI scan detected no brain alteration. Typical radiological signs are described in association to contrast encephalopathy. Nevertheless, vascular interventional physicians should be well aware of this condition also when those signs are lacking.

Preoperative Intrasac Thrombus Load Predicts Worse Outcome after Elective Endovascular Repair of Abdominal Aortic Aneurysms

PURPOSE To evaluate the impact of two-dimensional and three-dimensional preoperative morphologic features analyzed on computed tomography (CT) angiography on midterm outcome in patients with abdominal aortic aneurysms (AAAs) treated with endovascular aneurysm repair (EVAR). MATERIALS AND METHODS A retrospective analysis was conducted using a prospectively collected database. Morphologic features considered as potentially influencing outcomes were maximum aortic diameter, thrombus area, overall aneurysm volume, and intrasac thrombus volume. Outcome measures were all perioperative and midterm AAA-related reinterventions and all-cause mortality. RESULTS Investigators reviewed 191 preoperative CT angiography scans. Mean maximum aortic diameter was 58 mm; thrombus area, 49.6%; aortic volume, 159.36 cm(3); and thrombus volume, 58.6%. Technical success was achieved in all cases. No reintervention was required in the perioperative period, and there was no perioperative mortality. At a mean follow-up of 32 months ± 16.8 (range, 3-66 mo), mortality rate was 9.4%, AAA-related death was 0, and reintervention rate was 8.9%. Causes of reintervention included type I endoleak (n = 3 [1.6%]), type II endoleak (n = 7 [3.7%]), type III endoleak (n = 1 [0.5%]), endograft limb thrombosis (n = 4 [2.1%]), and access vessel thrombosis (n = 2; 1%). Greater thrombus area (> 60%) and thrombus volume (> 59%) were predictors for reintervention (P = .005 and P = .0034). Greater maximum aortic diameter (> 59 mm) and aortic volume (> 159 cm(3)) were related to higher reintervention rate without statistical significance (P = .62 and P = .12). Aortic volume was a predictor of any adverse event, reintervention, and all-cause mortality after EVAR (P = .03). CONCLUSIONS Thrombus area and volume are related to higher rates of reintervention. Maximum aortic diameter was related to a higher reintervention rate, but this was not significant.

Contralateral Occlusion Increases the Risk of Neurological Complications Associated with Carotid Endarterectomy

Objective. To report on the incidence and factors associated with the development of perioperative neurological complications following CEA in patients affected by carotid stenosis with contralateral occlusion (CO) and to compare results between those patients and the whole group of patients submitted to CEA at our vascular division from 1997 to 2012. Methods. Our nonrandomized prospective experience including 1639 patients consecutively submitted to CEA was retrospectively reviewed. 136 patients presented a CO contralateral to the treated carotid stenosis. Outcomes considered for analysis were perioperative neurological death rates, major and minor stroke rates, and a combined endpoint of all neurological complications. Results. CO patients more frequently were male, smokers, younger, and symptomatic (P < 0.001), presented with a preoperative brain infarct and associated peripheral arterial disease (P < 0.0001), and presented with higher perioperative major stroke rate than patients without CO (4.4% versus 1.2%, resp., P = 0.009). Factors associated with the highest neurological risk in CO patients were age >74 years and preoperative brain infarct (P = 0.03). The combination of the abovementioned factors significantly increased complication rates in CO patients submitted to CEA. Conclusions. In our experience CO patients were at high risk for postoperative neurological complications particularly when presenting association of advanced age and preoperative brain infarction.