Eleni Arnaoutoglou

Post-implantation syndrome following endovascular abdominal aortic aneurysm repair: preliminary data

OBJECTIVES Endovascular aneurysm repair (EVAR), may elicit an unexpected systemic inflammatory response, which has been named post-implantation syndrome (PIS). The aim of this study was to prospectively evaluate the association of PIS with clinical and laboratory parameters in patients who underwent EVAR for abdominal aortic aneurysms (AAA). METHODS Forty consecutive patients who underwent EVAR for AAA were studied. Complete blood count, fibrinogen, high sensitivity C-reactive protein (hs-CRP), interleukin (IL)-6, IL-1, tumor necrosis factor-alpha were determined before and after surgery. Several parameters regarding the operation, as well as the hospitalization days were recorded. RESULTS PIS was diagnosed in 35% of the patients. Patients with PIS showed significant greater changes of inflammation marker levels, including hs-CRP and IL-6, as compared with the non-PIS group. PIS was associated with longer hospitalization. CONCLUSION PIS is a relatively common complication of EVAR used to treat AAAs and it is associated with features of a systemic inflammatory response and prolongation of hospitalization. Further studies are necessary towards understanding the underlying pathophysiology and evaluating effective preventive strategies.

Post-implantation syndrome after endovascular repair of aortic aneurysms: need for postdischarge surveillance

OBJECTIVES To present the consequences and the need for readmission due to a vigorous inflammatory response in six patients who underwent endovascular repair of aortic aneurysms and developed post-implantation syndrome (PIS), during the postoperative period. METHODS From January 2007 to December 2009, 162 patients underwent endovascular repair of an aortic aneurysm. PIS was recorded in 49 patients. Among these, we present six patients who developed a systemic inflammatory response syndrome (SIRS) after discharge from hospital, which led to readmission within the first 30 postoperative days. RESULTS Five patients were treated for asymptomatic infrarenal abdominal aortic aneurysm and one for a thoracic one. All patients were discharged from hospital in the absence of any complications, fever or leukocytosis, but several days later they developed features of SIRS leading to readmission, even to the intensive care unit in two of them. After the administration of anti-inflammatory drugs all patients showed a complete recovery and finally left hospital several days later. CONCLUSIONS In some patients, the initial inflammatory response following endovascular aortic aneurysm repair is not always spontaneously attenuated and could lead to the development of SIRS even several days after the operation. It seems reasonable that patients developing PIS after endovascular aneurysm repair might be better kept under surveillance for the first postoperative month.

Endovascular repair of profunda femoral artery false aneurysms using covered stents.

Pseudoaneurysms of the profunda femoral artery (PFA) have been reported following different types of trauma, mostly iatrogenic. We present three cases of PFA false aneurysm formation, two after vascular procedures and one as a result of a gunshot injury, which were successfully treated with the endovascular deployment of covered stents. Treating these patients by endoluminal means is an efficient and feasible minimally invasive approach. If the patient is relatively stable and there are no major compression issues, stenting could be considered as adequate therapy for these situations. Certainly, a larger series are needed in order to testify to the long-term results and ascertain the durability of such a repair.

Effects of rosuvastatin with or without ezetimibe on clinical outcomes in patients undergoing elective vascular surgery: results of a pilot study.

Objective: Cardiovascular complications represent a major cause of morbidity and mortality in patients undergoing vascular surgery. This was a prospective randomized, open-label study to investigate the effect of lipid-lowering treatment by statin monotherapy or intensified by combining statin with ezetimibe on a 12-month prognosis after vascular surgery. Methods: Patients were randomly assigned to receive rosuvastatin (RSV) 10 mg/d or rosuvastatin 10 mg/d plus ezetemibe (RSV/EZT) 10 mg/d, starting prior to scheduled surgical procedure. The primary end point was the first major cardiovascular event, including death from cardiac causes, nonfatal myocardial infarction, ischemic stroke, and unstable angina. Results: A total of 136 patients assigned to RSV and 126 to RSV/EZT completed the study protocol. As many as 6.6% of patients in the RSV group experience a major cardiovascular event within 30 days after surgery versus 5.6% in the RSV/EZT group (P = .72). From month 1 to 12 of the follow-up period, primary end point was observed (9 taking RSV vs 2 in the RSV/EZT group [P = .04]). Intensified lipid-lowering therapy with RSV/EZT was associated with a greater decrease in low-density lipoprotein cholesterol levels compared with RSV (75.87 ± 31.64 vs 87.19 ± 31.7, P = .004), while no differential effect on triglyceride, high-density lipoprotein cholesterol or high-sensitivity C-reactive protein levels was noted between groups. Conclusion: Our findings indicate that statin therapy intensified by ezetimibe may reduce the incidence of cardiovascular events within the first 12 months after vascular surgery. Nonetheless, whether the use of ezetimibe as an add-on therapy to reduce cardiovascular risk in these patients needs to be tested in larger future studies.

Postoperative levels of cardiac troponin versus CK-MB and high-sensitivity C-reactive protein for the prediction of 1-year cardiovascular outcome in patients undergoing vascular surgery

ObjectiveThis study evaluated comparatively the predictive value of postoperative cardiac troponin I (cTnI), creatinine kinase (CK)-MB, and high-sensitivity C-reactive protein (hs-CRP) in 1-year cardiovascular mortality and morbidity in patients undergoing elective vascular surgery. MethodsA total of 295 consecutive patients undergoing elective noncardiac vascular surgery were prospectively followed-up over a period of 12 months. The levels of cTnI, CK-MB, and hs-CRP were measured preoperatively and 24 h after operation. The primary endpoint was the composite of cardiovascular death, nonfatal acute myocardial infarction, ischemic stroke, and unstable angina. ResultsThe primary endpoints occurred in 11 patients (3.8%). Receiver operating characteristic curve analysis showed that postoperative cTnI was a strong predictor of a cardiovascular event during 1-year follow-up (area under the curve, 0.852; P<0.001). Areas under the curve for hs-CRP and for CK-MB were 0.734 (P=0.008) and 0.494 (P=0.947). A threshold cTnI value of 0.4 ng/ml was highly associated with the occurrence of a cardiovascular event, with a sensitivity of 80% and specificity of 81%. Furthermore, cTnI levels provided a significantly better prediction than CK-MB levels (P=0.009) and tended to be superior to hs-CRP (P=0.2). ConclusionPostoperative cTnI levels seem to be superior to CK-MB and hs-CRP levels for the prediction of 1-year cardiovascular mortality and morbidity in patients undergoing elective vascular surgery.

Standard endovascular treatment of abdominal aortic aneurysms in patients with very short proximal necks using the Endurant stent graft

OBJECTIVE This study evaluated and compared the midterm results of endovascular aortic aneurysm repair with the Endurant (Medtronic Inc, Santa Rosa, Calif) stent graft system in off-label use in patients with short (<10 mm) proximal aortic necks and in patients treated according to device-specific instructions for use. METHODS This was a case-control (2:1) single-center retrospective analysis of prospectively collected data performed between September 2008 and December 2012. Analysis identified 19 elective patients with short (<10 mm) proximal necks and mild angulations (≤45°) treated with the Endurant stent graft and 38 patients matched for age, sex, and aneurysm diameter with proximal aortic necks ≥10 mm in length who met the instructions for use. End points included technical and clinical success and freedom from any secondary intervention, any type of endoleak, and aneurysm-related death. RESULTS The short-neck group was a mean ± standard deviation age of 71.7 ± 8.9 years, 84% were men, and their mean infrarenal aortic neck length was 6.1 ± 1.2 mm. Mean suprarenal and infrarenal angles were 110° ± 10.4° and 170° ± 15.4°, respectively. Aortic neck diameters were similar between the groups (26.6 ± 3.8 vs 25.7 ± 3.7 mm; P = .36). Primary technical success was achieved in all cases. Off-label patients were more likely to require additional proximal cuff deployment to successfully obtain a seal (21% vs 3%; P = .04). The two patient groups were similar in rates of perioperative mortality, morbidity, and complications. Mean follow-up of 24 ± 12 months revealed no differences in clinical success, freedom from reintervention, and aneurysm-related death. No type I endoleaks were observed in either group during the follow-up period. CONCLUSIONS The Endurant stent graft system applied off-label in patients with very short aneurysm necks (<10 mm) with mild angulation showed acceptable treatment results. These midterm results might suggest its use in carefully selected patients with very short neck anatomy. Long-term data are needed to verify the observed durability of the Endurant stent graft.

An Update on the Inflammatory Response after Endovascular Repair for Abdominal Aortic Aneurysm

Postimplantation syndrome (PIS) is the clinical and biochemical expression of an inflammatory response following endovascular repair of an aortic aneurysm (EVAR). The goal of this review is to provide an update on the inflammatory response after endovascular repair of abdominal aortic aneurysm, discussing its causes and effects on the clinical outcome of the patient. PIS concerns nearly one-third of patients after EVAR. It is generally a benign condition, although in some patients it may negatively affect outcome. The different definitions and conclusions drawn from several studies reveal that PIS needs to be redefined with standardized diagnostic criteria. The type of the endografts material seems to play a role in the inflammatory response. Future studies should focus on a better understanding of the underlying pathophysiology, predictors, and risk factors as well as determining whether effective preventive strategies are necessary.

Cerebral oximetry and stump pressure as indicators for shunting during carotid endarterectomy: comparative evaluation

The purpose of this work is to investigate the correlation between regional oxygen saturation (rSO2) changes and stump pressure (SP) during cross-clamping of the internal carotid artery in carotid endarterectomy (CEA) and verify the perspectives of rSO2 to become a criterion for shunting. Sixty consecutive CEAs under general anesthesia were studied prospectively. Selective shunting was based on SP ≤40 mmHg exclusively. Regression analysis with high order terms and receiver operating characteristic analysis were performed to investigate the association between ΔrSO2(%) and SP and to determine an optimal ΔrSO2(%) threshold for shunt insertion. A quadratic association between ΔrSO2(%) and SP was documented regarding the baseline to one and five minutes after cross-clamping intervals. A cut-off of 21 and 10.1% reduction from the baseline recording was identified as optimal for the distinction between patients needed or not a shunt regarding the first and fifth minute after cross-clamping, respectively. In conclusion, cerebral oximety reflects sufficiently cerebral oxygenation during CEA compared with SP, providing a useful mean for cerebral monitoring.

Endovascular repair of blunt axillo-subclavian arterial injuries as the first line treatment.

AIM To report and analyse our results regarding the endovascular management of blunt axillo-subclavian arterial injuries as the first line treatment. METHODS During an eight-year period, seven patients (mean age 56.4±14.1 years, all males) with blunt traumatic axillo-subclavian arterial injuries were presented to the emergency department. All patients suffered also from concomitant other injuries and had a supraclavicular haematoma along with diminished or absent upper limb peripheral pulses, while computed tomography angiography set the diagnosis. RESULTS The endovascular procedure was technically successful in all patients. No procedure-related complication was encountered during the in-hospital stay, while none of the patients died. The median hospital stay was 22 days (range 12-46). During a follow-up period spanning an average of 27 months (range 6-44 months) there was one stent-graft thrombosis at 12 months in an otherwise asymptomatic patient that required no further intervention. CONCLUSION Endovascular technique seems to constitute a reliable approach for treating blunt axillo-subclavian arterial injuries in the emergent setting. Despite uncertainties in patient selection and optimal management algorithms, it seems that endovascular approach could be the first line treatment for such injuries. Accumulation of data on larger number of patients with longer follow-up is warranted to further define the value of this therapeutic modality in the trauma setting.

Stenting of the descending thoracic aorta: a six-year single-center experience

OBJECTIVES The aim of this study was to review the six-year results of the endovascular repair of descending thoracic aortic pathologies, reporting the early perioperative outcomes as well as the mid-term follow-up of the treated patients. METHODS Fifty-five consecutive patients who underwent endovascular repair for thoracic aortic pathology (32 aneurysms, 17 acute thoracic aortic syndromes, and six traumatic aortic ruptures) during a six-year period were retrospectively reviewed. From these patients, 30 (54.5%) were treated electively and 25 (45.5%) on an emergency basis. In eight cases (14.5%) there was a need for left subclavian artery orifice overstenting. In seven patients (12.7%) an abdominal aortic lesion was simultaneously treated, while three more patients (5.5%) had previously had their abdominal aortic aneurysm repaired. RESULTS The primary technical success was 92.7%. Seven patients (12.7%) underwent some operation related complication, while postoperative complications occurred in five patients (9.1%), namely four myocardial infarctions, one acute respiratory distress syndrome and two delayed parapareses resulting in an overall incidence of neurological complications of 3.6%. The combined 30-day and in-hospital mortality was 9.1%, exclusively related to patients treated emergently (P = 0.01). In a mean follow-up period of 34 months there were six deaths, and the overall cumulative survival at four years was estimated at 72.6%. Only one type II endoleak was observed one month after the procedure and it spontaneously disappeared 18 months later. CONCLUSIONS The endovascular repair of descending thoracic aortic pathologies seems to be a well-established method, with favorable morbidity and mortality rates, at least for 30 days and in the mid-term. Taking into account the potential of a wide application of the endovascular technique in many vascular centers, stenting of the thoracic aorta might offer an overall better solution for patients suffering from these devastating pathologies.