Domenico Angiletta

Comparison of Early and Midterm Results of Open and Endovascular Treatment of Popliteal Artery Aneurysms

BACKGROUND Aim of this study was to retrospectively compare perioperative (<30 days) and 2-year results of open and endovascular management of popliteal artery aneurysms (PAAs) in a single-center experience. METHODS From January 2005 to December 2010, 64 PAAs in 59 consecutive patients were operated on at our institution; in 43 cases, open repair was performed (group 1), whereas the remaining 21 cases had an endovascular procedure (group 2). Data from all the interventions were prospectively collected in a dedicated database, which included main preoperative, intraoperative, and postoperative parameters. Early results in terms of mortality, graft thrombosis, and amputation rates were analyzed and compared by χ(2) text or Fisher exact text. The surveillance program consisted of clinical and ultrasonographic examinations at 1, 6, and 12 months and yearly thereafter. Follow-up results (survival, primary and secondary patency, limb salvage) were analyzed by Kaplan-Meier curves, and differences in the two groups were assessed by log-rank test. RESULTS There were no differences between the two groups in terms of sex, age, risk factors for atherosclerosis, and comorbidities; PAAs were symptomatic in 48% of cases in group 1 and in 29% in group 2 (P = 0.1). Fifteen patients with mild-to-moderate acute ischemia due to PAA thrombosis underwent preoperative intra-arterial thrombolysis, 13 in group 1 and 2 in group 2. In open surgery group, nine cases were treated with aneurysmectomy and prosthetic graft interposition, and in seven cases, the aneurysm was opened and a prosthetic graft was placed inside the aneurysm. In 27 cases, ligation of the aneurysm with bypass grafting (21 prosthetic grafts and 6 autologous veins) was carried out. In group 2, 20 patients had endoprosthesis placement, whereas in the remaining patient, a multilayer nitinol stent was used. There was one perioperative death in a patient of group 2 who underwent concomitant endovascular aneurysm repair and PAA endografting. Cumulative 30-day death and amputation rate was 4.5% in group 1 and 4.7% in group 2 (P = 0.9). Follow-up was available in 61 interventions (96%) with a mean follow-up period of 22.5 months (range: 1-60). Estimated primary patency rates at 24 months were 78.1% in group 1 and 59.4% in group 2 (P = 0.1). Freedom from reintervention rates at 24 months were 79% in group 1 and 61.5% in group 2 (P = 0.2); estimated 24-month secondary patency rates were 81.6% in group 1 and 78.4% in group 2 (P = 0.9), and freedom from amputation rates were 92.7% and 95%, respectively (P = 0.7). CONCLUSIONS Endovascular treatment of PAAs provided, in our initial experience, satisfactory perioperative and 1-year results, not significantly different from those obtained with prosthetic open repair in patients with similar clinical and anatomical status. There is, however, a trend toward poorer primary patency rates among patients endovascularly treated, who also seem to require more frequently a reintervention.

Gender-related outcomes in the endovascular treatment of infrainguinal arterial obstructive disease

OBJECTIVE The purpose of this study was to retrospectively analyze early and midterm results of endovascular infrainguinal peripheral revascularizations in female patients in our single-center experience, paying particular attention to clinical, anatomic, and technical factors affecting perioperative and follow-up outcomes. MATERIALS AND METHODS From January 2000 to December 2010, 258 endovascular interventions for femoropopliteal disease were performed. Interventions were retrospectively divided into two groups: interventions performed in women (80 interventions, group 1) and interventions performed in men (178 interventions, group 2). The two groups of patients were compared in terms of demographic data, common risk factors for atherosclerosis, and comorbidities. Early (intraoperative and <30-day) results were analyzed in terms of technical success, conversion to open surgery, primary patency, secondary patency, and, for patients with critical limb ischemia, limb salvage. The follow-up program consisted of clinical and duplex scanning examinations with ankle-brachial index (ABI) measurement within the third postoperative month, at 6 and 12 months, and yearly thereafter. Follow-up results were analyzed in terms of survival, primary and secondary patency, assisted primary patency, and, for patients with critical ischemia, limb salvage. RESULTS There were no differences between the two groups in terms of risk factors for atherosclerosis, comorbidities, clinical, and anatomic status. Technical success was 96.9% and technical failure rates were 1.2% in group 1 and 3.9% in group 2 (P = .2). Three in-hospital deaths were recorded, all in group 2, whereas in-hospital thromboses occurred in five patients, two in group 1 and three in group 2; with conversion to surgical bypass in all these cases, and in three of the cases, major amputation was necessary (two in group 1 and one in group 2). Cumulative 30-day mortality was 1.1%, with no difference between women (no deaths) and men (three deaths, 1.6%; P = .4). Overall amputation rate at 30 days was 1.2%, again with no differences between the two groups (2.5% and 0.6%, respectively; P = .4); also, the rate of perioperative thrombosis (overall 2.7%) was similar between the two groups (2.5% and 3.3%, respectively; P = .9). Mean duration of follow-up was 17 months (range, 1-85 months). Estimated 36-month survival rates were 95% in group 1 and 84.5% in group 2 (P = .4; log-rank, 0.7). Cumulative primary patency rates at 36 months were 38% in group 1 and 42% in group 2 (P = .4; log-rank, 0.5). Assisted primary patency at 36 months was 45.1% in group 1 and 60.5% in group 2, whereas secondary patency rates were 63.5% and 76%, respectively (P = .8; log-rank, 0.03). CONCLUSION Endovascular treatment of femoropopliteal occlusive disease provides similar results between men and women at an intermediate follow-up. There is, however, a trend toward poorer results in women requiring further analysis at a longer follow-up period.

Cardiovascular risk factors in patients on long-term treatment with nevirapine- or efavirenz-based regimens

OBJECTIVES The aim of this study was to evaluate the cardiovascular risk among patients treated for more than 5 years with regimens based on nevirapine or efavirenz. PATIENTS AND METHODS A total of 276 patients were retrospectively evaluated, 156 of whom were treated with nevirapine and 120 with efavirenz, by examining traditional risk factors and detecting the presence of subclinical carotid lesions with colour-Doppler ultrasonography. RESULTS When comparing the data at baseline and follow-up in the nevirapine group, total cholesterol, low-density lipoprotein cholesterol (LDLc) and triglycerides showed a significant decrease, while high-density lipoprotein cholesterol increased. Ultrasound data, obtained in a subgroup of 67 patients, did not show significant changes for those treated with nevirapine. In the efavirenz group, total cholesterol, LDLc, triglycerides, glycaemia, body mass index and the number of patients with a pathological ultrasound significantly increased. When comparing the two groups at baseline and follow-up, nevirapine patients had significantly higher values of total cholesterol, LDLc and triglycerides at baseline, while total cholesterol and LDLc differed non-significantly at follow-up; triglycerides became significantly lower in the nevirapine arm with respect to the efavirenz group. Glycaemia was comparable between the two groups at baseline, while it was significantly lower in the nevirapine group at follow-up. The number of pathological ultrasound findings was significantly higher in the efavirenz group at follow-up. CONCLUSIONS Patients treated with nevirapine demonstrated a better lipid and glucose profile and a lower tendency to develop subclinical atherosclerotic lesions.

Comparison of Open and Endovascular Treatments of Post-carotid Endarterectomy Restenosis

AIM OF THE STUDY To compare early and long term results of open and endovascular treatment of post-carotid endarterectomy (CEA) restenosis in a single centre experience. METHODS From January 2005 to December 2011, ninety-nine consecutive interventions for primary severe post-CEA restenosis were performed: in 41 cases (41%, Group 1) open repair was carried out, whereas the remaining 58 patients (59%, group 2) underwent an endovascular treatment. Data concerning these interventions were prospectively collected in a dedicated database containing main pre, intra and postoperative variables. Early results in terms of 30-day stroke and death rates were analysed and compared with χ(2) test. Follow-up results were analysed with Kaplan Meier curves and compared with log-rank test. RESULTS Mean time from primary CEA was 75 months in group 1 and 42 months in group 2 (p = 0.002; 95% CI 12-52). There were no differences between the two groups in terms of demographic data, comorbidities, risk factors for atherosclerosis, preoperative clinical status or degree of stenosis on the operated side. In group 1 interventions consisted of redo-CEA in 37 patients and of carotid bypass in the remaining 4; all the patients in group 2 underwent stent placement with cerebral protection device. No perioperative deaths and ipsilateral neurological events occurred in both groups. One patient in group 1 suffered from a non-fatal acute myocardial infarction. Other six patients (14.5%) experienced transient cranial nerve injuries, with complete regression at 1-month follow-up; two patients had postoperative dysphagia due to neck haematoma, which was medically managed. Neither access-related nor systemic complications were recorded in group 2. Follow-up was available in 98% of the patients with a median duration of 24 months (range 3-72). There were no differences in terms of 4-year estimated survival and stroke-free survival, whereas patients in group 1 were more likely to develop severe (>80%) secondary restenosis (28.3% and 6.5%, respectively, p = 0.01, log rank 6.3) and to undergo secondary reintervention (22% and 11%, respectively p = 0.01, log rank 6). CONCLUSIONS despite the selection limits and bias of this study, in our experience open and endovascular surgery provided similar perioperative results in the management of post-CEA restenosis. Long term outcomes are similar, too, despite a slight increase in secondary restenosis and recurrent reinterventions among open surgery patients, warranting further studies and analysis.

Early and Intermediate Results of Elective Endovascular Treatment of True Visceral Artery Aneurysms

BACKGROUND To retrospectively analyze early and follow-up results of endovascular management of visceral artery aneurysms (VAAs) in a single-center experience. METHODS From 2007 to June 2013, 26 consecutive elective endovascular interventions for VAAs were performed in 26 patients; preoperative, intraoperative, and postoperative data were prospectively collected in a dedicated database. Early (<30 days) and follow-up results were evaluated. RESULTS The site of aneurysm was splenic artery in 17 patients, common hepatic artery in 3 patients, renal artery and pancreaticoduodenal artery in 2 cases each, and gastroduodenal artery and celiac trunk in one case each. All the lesions were asymptomatic, and the mean diameter was 22.8 mm. Interventions consisted in coiling in 19 cases; in 4 patients a covered stent was placed, whereas the remaining 3 patients had a multilayer stent. Technical success was 89%. There were no perioperative deaths; 1 patient with splenic artery aneurysm had coils migration with symptomatic splenic infarction and underwent successful redo coils packing. Median duration of follow-up was 18 months. During follow-up, 1 aneurysm-unrelated death occurred. One asymptomatic thrombosis of a treated vessel was recorded, with a 2-year estimated patency rate of 91%. Mean aneurysmal diameter at the latest follow-up was 20.2 mm (P = 0.001 in comparison with preoperative values; 95% confidence interval 1.9-5.2). Complete exclusion of the aneurysm occurred in all but 1 patient, who had a limited increasing in the diameter of its splenic aneurysmal sac after coiling. Another patient developed a more distal aneurysm of the splenic artery after 24 months. No reinterventions were required. Freedom from aneurysm-related complications at 2 years was 72.9% (Standard Error, 0.09). CONCLUSIONS In our experience, endovascular treatment of VAA, when feasible, provided excellent perioperative results with low rates of complications and reinterventions. Even if the risk of developing aneurysm-related complications during follow-up is substantial, most of them can be watched without the need for repeated interventions.

Surgical and endovascular treatment of extracranial carotid artery aneurysms: early and long-term results of a single center.

PURPOSE To evaluate early and long-term results of surgical and endovascular therapy of extracranial carotid artery aneurysms. PATIENTS AND METHODS A retrospective study was conducted of 26 aneurysms in 25 patients (19 men and 6 women) who underwent surgery between 1993 and 2010: 18 were atherosclerotic, 3 were from arteritis, 1 was a relapsing mycotic aneurysm from previous carotid surgery, and 4 were posttraumatic. A neurologic event was the presenting symptom in 10 cases (7 transient ischemic attacks, 3 strokes); 13 patients were asymptomatic and a cranial nerve dysfunction (hoarseness) was present in 2; fever was present in 1. A total of 15 aneurysms, located on the carotid bifurcation (CB), were resected and an end-to-end carotid anastomosis was performed. In 6 patients with CB aneurysms, a vein graft was applied in 5, and a polytetrafluoroethylene graft in the other. Aneurysmorrhaphy and a vein patch was the procedure in 2 patients with an aneurysm of the CB. One of these 2 patients had a relapsing mycotic pseudoaneurysm and was treated initially with a vein patch, subsequently with a vein graft, and lastly with a carotid artery ligation. Three common carotid artery aneurysms from arteritis were treated under local anesthesia through implantation of a Viabahn endoprosthesis. RESULTS A perioperative minor stroke occurred in 1 patient (3.8%) because of intentional ligation of the internal carotid artery from a relapsing mycotic aneurysm, already treated with a vein patch and subsequently with a vein bypass. No permanent cranial nerve injuries were recorded; transient cranial nerve injuries were observed in 2 patients. CONCLUSIONS Surgical treatment is feasible, with an acceptable rate of stroke and cranial nerve injuries, especially when the aneurysm is located on the common carotid artery and carotid bulb. Endovascular therapy is a fascinating option, with satisfactory early and long-term results, and should always be considered when treating aneurysms located in the distal internal carotid artery and when the patient is not a good candidate for open surgery.

Spinal cord, bowel, and buttock ischemia after endovascular aneurysm repair.

A 66-year-old man with multiple comorbidities presented with a juxtarenal perianastomotic aortic aneurysm 10 years after open abdominal aortic aneurysm repair. The aneurysmal disease also involved both iliac bifurcations, the right internal iliac artery, the left common femoral artery (CFA) up to its bifurcation, and the homolateral popliteal artery. We performed bilateral internal iliac artery coil embolization 1-month apart. Later, we performed aortouniiliac endografting extending to the right external iliac artery and placement of an endovascular plug in the left external iliac artery. A right CFA to left femoral bifurcation bypass graft was then constructed after ligation of the left CFA aneurysm. After recovering from anesthesia and despite sequential hypogastric embolization, the patient developed postoperative paraplegia, buttock ischemia, and ischemic colitis and died on postoperative day 5. The possible pathogenic mechanisms involved in the onset of these ischemic complications are discussed in this article.

Eight-year follow-up of endovascular repair of a brachiocephalic trunk aneurysm due to Takayasu's arteritis

Aneurysms of the brachiocephalic trunk are rare but their clinical outcomes are potentially devastating; they include rupture, cerebral or arm ischemia secondary to thromboembolism, and compression of the surrounding structures. Although open repair has proven successful, it is associated with significant morbidity and mortality rates. Endovascular treatment, if anatomically feasible, may offer a safer and less invasive approach to these lesions, especially in high-surgical-risk patients. We report the good long-term outcome of endovascular repair of a large innominate artery true aneurysm due to Takayasus arteritis. A stent graft was safely and successfully deployed to exclude the aneurysm; assessment by vascular imaging at 8-year follow-up demonstrated the efficacy of the procedure.

Leiomyosarcoma of the Inferior Vena Cava: Resection and Vascular Reconstruction Using a Dacron Graft and an Adam De Weese Clip—Three-Year Follow-Up

Leiomyosarcomas are rare malignant tumors that particularly affect women. In 2% of all cases, they involve the veins, and in 60% of the cases affecting veins, an involvement of the inferior vena cava (IVC) has been demonstrated. We report a case of IVC leiomyosarcoma operated by resection and reconstruction with a Dacron bypass and apposition of an Adams-DeWeese IVC filter. The latter procedure has never been reported before in association with a graft applied for this disease. Technical and clinical details are described.

High-sensitivity C-reactive protein predicts cardiovascular events and myocardial damage after vascular surgery

OBJECTIVE To assess the association of high-sensitivity C-reactive protein (hsCRP) to adverse cardiovascular events and perioperative myocardial damage in patients after elective vascular surgery. METHODS This was a prospective observational study in a tertiary-care teaching hospital, with 239 patients undergoing elective vascular surgery. The receiver-operating characteristic (ROC) curve was calculated to assess the optimal cut-off value of hsCRP. Odds ratios (ORs) with 95% confidence intervals (CIs) were calculated. Multiple logistic regression analysis was used to identify the predictors of the primary outcome. The primary outcome was a composite of periprocedural myocardial damage, defined as cardiac troponin I (cTn-I) elevation above the decision limit of 0.15 μg/L, death, acute coronary syndrome, stroke, acute heart failure, or intrastent thrombosis within 30 days of surgery. RESULTS On ROC analysis, the optimal cut-off value of hsCRP was 3.2 mg/L. The primary outcome occurred in 48 patients (20.1%). On univariate analysis, smoking (P = .009), known hypercholesterolemia (P = .01), previous ischemic heart disease (P = .0003), open surgery (P = .03), and hsCRP levels (P < .0001) were associated with the primary outcome. On multiple logistic regression analysis, only hsCRP was independently associated with the primary outcome. The unadjusted and adjusted ORs for the primary outcome among patients with hsCRP levels >3.2 mg/L were 7.5 (CI, 3.7-15.2; P < .0001) and 4.6 (CI, 2.1-9.9; P = .0001), respectively. CONCLUSION Our data suggest that higher levels of hsCRP are independently associated with an increased risk of perioperative myocardial damage and early adverse cardiovascular events in patients undergoing elective vascular surgery. This may have implications for risk stratification and therapeutic approach.