Enrico Maria Marone

Is Open Repair Still the Gold Standard in Visceral Artery Aneurysm Management

BACKGROUND Visceral artery aneurysms and pseudoaneurysms represent a rare disease with high mortality. The aim of this study was to report a single center experience of open repair (OR) and endovascular treatment (ET) of 94 patients, and to analyze short- and midterm results. METHODS Between 1988 and 2010, 94 patients, 43 men and 51 women, mean age of 57.6 years (range, 23-87 years), were referred to our Institute with a diagnosis of visceral artery aneurysm or pseudoaneurysm. Arteries involved were splenic artery in 44 cases, hepatic artery in 17, renal artery in 18, superior mesenteric artery in six, celiac trunk in three, gastroduodenal in two, and pancreaticoduodenal in four. An abdominal aortic aneurysm coexisted in three (3%) cases, whereas in six (6%) cases, there were multiple visceral aneurysms. ET was indicated based on the anatomical location of the aneurysm or for patients at high risk for surgery. RESULTS A total of 74 patients underwent OR, whereas ET was performed in 20 patients. Technical success was achieved in all cases treated by open surgery. Splenectomy was performed in 11 cases, and in six, splenic autotransplantation was performed. At 6 months of follow-up, a Tc99m-labeled red cell scintigraphy showed that autotransplants were viable in four patients (67%). No cases of pancreatitis or splenic infarction were observed. Among renal artery aneurysms, nephrectomy was necessary in one case of renal infarction for massive thrombosis of the ex-vivo reconstructed renal artery. Four surgical conversions were recorded (one thrombosis of the hepatic artery, one massive hemorrhage after embolization of superior mesenteric artery aneurysm, and two cases of sac enlargement after 24 and 48 months). An endoleak was present in a patient treated for a splenic artery aneurysm, but it resolved spontaneously after 6 months. No complications were observed in patients undergoing surgical conversion after ET. Perioperative mortality in the surgical group was 1.3% (1/74). There was no perioperative mortality in the endovascular group. No statistically significant difference was found between groups in terms of perioperative mortality (p = 1.00). Perioperative morbidity was 9.4% (7/74) in the surgical group, and 10% (2/20) in the endovascular group (p = 1.00). Follow-up was available for 16 patients in the endovascular group (80%) and 63 in the surgical group (85%), with a mean duration of 42 months (1-192 months). In the whole cohort, actuarial survival at 10 years was 68%. The Kaplan-Meier estimates of survival at 1 and 5 years were 100% and 85%, respectively, for OR, and 100% and 40%, respectively, for ET, with no significant difference between the two groups CONCLUSION ET is safe and feasible in selected patients, but incomplete exclusion may be observed, requiring late surgical conversion in a significant number of patients. Long-term results (high survival, low complication rate) confirm the durability of the surgical approach that in our experience remains the gold standard with satisfactory results, especially for aneurysms involving the visceral hilum.

Aorto-oesophageal and aortobronchial fistulae following thoracic endovascular aortic repair: a national survey.

OBJECTIVE We evaluated the incidence of aorto-oesophageal (AEF) and aortobronchial (ABF) fistulae after thoracic endovascular aortic repair (TEVAR), and investigated their clinical features, determinants, therapeutic options and results. METHODS We conducted a voluntary national survey among Italian universities and hospital centres with a thoracic endovascular programme. RESULTS Thirty-nine centres were contacted, and 17 participated. Of the patients who underwent TEVAR between 1998 and 2008, 19/1113 (1.7%) developed AEF/ABF. Among indications to TEVAR, aortic pseudo-aneurysm was associated with the development of late AEF/ABF (P = 0.009). Further, emergent and complicated procedures resulted in increased risk of AEF/ABF (P = 0.008 and P < 0.001, respectively). Eight patients were treated conservatively, all of whom died within 30 days. Eleven patients underwent AEF/ABF surgical treatment, with a perioperative mortality of 64% (7/11). At a mean follow-up of 17.7 +/- 12.5 months, overall survival was 16% (3/19). CONCLUSIONS The incidence of AEF and ABF following TEVAR is not negligible, and is comparable to that following open repair. This finding warrants an ad hoc long-term follow-up after TEVAR, particularly in patients submitted to emergent and complicated procedures. Both surgical and endovascular treatment of AEF/ABF are associated with high mortality. However, conservative treatment does not appear to be a viable option.

Endovascular treatment of aortoesophageal and aortobronchial fistulae

BACKGROUND Even when promptly recognized and treated, aortoesophageal (AEF) and aortobronchial (ABF) fistulae are highly lethal conditions. Open surgical repair also carries a high risk of mortality and morbidity. Several alternative strategies have been recently reported in the literature including thoracic endovascular aortic repair (TEVAR). However, relatively little is known about results of TEVAR for AEF and ABF due to their rarity and the lack of large surveys. METHODS A voluntary national survey was conducted among Italian universities and hospital centers with an endovascular program. Questionnaires were distributed by e-mail to participating centers and aimed to evaluate the results of endovascular repair of established AEF or ABF. RESULTS Seventeen centers agreed to participate and provided data on their patients. Between 1998 and 2008, a total of 1138 patients were treated with TEVAR. In 25 patients (2.2%), the indication to treatment was an AEF and/or an ABF. In 10 of these cases (40%), an associated open surgical procedure was also performed. Thirty-day mortality rate of AEF/ABF endovascular repair was 28% (7 cases). No cases of paraplegia or stroke were observed. Mean follow-up was 22.6 months (range, 1-62). Actuarial survival at 2 years was 55%. Among the 18 initial survivors, five patients (28%) underwent reintervention due to late TEVAR failure. CONCLUSIONS Stent grafting for AEF and ABF represents a viable option in emergent and urgent settings. However, further esophageal or bronchial repair is necessary in most cases. Despite less invasive attempts, mortality associated with these conditions remains very high.

Ten years of endovascular aortic arch repair.

Purpose: To evaluate a 10-year single-center experience of arch endovascular aortic repair (AEVAR) using the hybrid approach. Methods: Between 1999 and 2009, 311 patients were treated with endografts for thoracic aortic pathologies. The aortic arch was involved in 116 (37.3%) patients (97 men; mean age 70.3±10.7 years, range 27–84). There were 83 atherosclerotic aneurysms, 21 type B dissections, and 12 other lesions whose proximal landing zones were categorized according to Ishimarus classification as 24 zone 0, 27 zone 1, and 65 zone 2. A hybrid approach was performed for all zone 0 and zone 1 procedures and in nearly half (47.7%) of zone 2 procedures. Early and midterm outcomes were reviewed retrospectively. Results: The initial clinical success in zone 0 aneurysms was 83.3%, with a 30-day mortality of 12.5% due to intraoperative stroke in all the cases. The respiratory failure rate was 12.5%, and there was 1 type I endoleak that spontaneously resolved at follow-up. Midterm clinical success at a mean 26±21 months was 83.3%. In zone 1 aneurysms, the initial clinical success was 82.1% without 30-day mortality or perioperative stroke. The midterm clinical success was 81.5% at a mean 21±17 months [2 (7.4%) late aneurysm-related deaths]. Four type I endoleaks spontaneously resolved in 3 patients. In zone 2 cases, the initial clinical success was 90.8%. There was 1 (1.5%) intraoperative death and another (1.5%) within 30 days; 1 (1.5%) patient suffered a stroke, and the respiratory and renal failure rates were 3.0%, respectively. This is the only zone in which paraplegia (2 patients, 3.0%) was encountered. The midterm clinical success was 93.9% at a mean 34±20 months. Four type I endoleaks spontaneously resolved in 3 patients at follow-up. Conclusion: In selected patients, early and midterm outcomes of AEVAR using the hybrid approach are promising; however, mortality and morbidity, especially for zones 0 and 1, are not negligible. Our results may have practical implications for the ongoing evolution of the hybrid procedure in the aortic arch, as well as for patients fit for traditional surgery.

Aortobifemoral Bypass Grafting Using Expanded Polytetrafluoroethylene Stretch Grafts in Patients with Occlusive Atherosclerotic Disease

The aim of this retrospective study was to evaluate the performance of bifurcated, longitudinally extensible (stretch), expanded polytetrafluoroethylene (ePTFE) grafts implanted in patients with aortoiliac or aortofemoral occlusive atherosclerotic disease. Between October 1991 and December 2005, 822 consecutive patients (708 men, 114 women; mean age 63.8 years) underwent aortoiliac or aortofemoral reconstruction using a bifurcated ePTFE stretch graft. Preoperatively, all patients had ultrasonographic and arteriographic evaluations and were divided into groups according to the TASC II morphological stratification of iliac lesions. Seventy-seven patients (9.4%) had type B lesions, 314 (38.2%) had type C lesions, and 431 (52.4%) were classified as type D lesions. Endarterectomy of the aorta was required in 172 patients (21%); femoral arteries were endarterectomized in 222 (27%). Femoropopliteal bypass grafting was performed in 18 patients, aortorenal bypass in 12, and mesenteric artery grafting in one. One patient died perioperatively of a myocardial infarction. Perioperative morbidity included cardiac (2.2% of patients), respiratory (0.9%), and gastrointestinal (1.2%) complications, as well as acute renal insufficiency (1.3%). Seven patients had bleeding requiring surgical revision within the first 24hr after surgery. There were four cases (0.5%) of immediate graft thrombosis and five (0.6%) of single-limb graft thrombosis. During a mean follow-up time of 72 months (range 28-170), 58 patients (7.1%) were lost to follow-up and 205 patients (24.9%) died. The primary and secondary graft-patency rates during the observation period were 90.6% and 97.9%, respectively. Twelve late graft occlusions resolved after thrombectomy alone. Eleven cases of single-limb late thrombosis resolved after thrombectomy and profundoplasty. The limb-salvage rate during the observation period in patients who underwent operation for critical limb ischemia was 84.5%. There were nine postoperative graft infections (1.1% infection rate) in the series. Our long-term experience with ePTFE stretch grafts in aortoiliac and aortofemoral reconstruction shows that these prostheses have a high rate of patency and a low rate of graft-related complications.

Effect of Chronic Venous Insufficiency on Activities of Daily Living and Quality of Life: Correlation of Demographic Factors With Duplex Ultrasonography Findings:

The study evaluates to what extent symptoms of chronic venous insufficiency (CVI) and functional venous incompetence as investigated using color-coded duplex ultrasonography may interfere with activities of daily living (ADLs). This study comprises a cross-sectional survey conducted in urban areas surrounding 24 Italian cities. A spontaneous sample of 5187 subjects (4457 women [mean age, 54 years] and 730 men [mean age, 61 years]), selected by advertising on television and in newspapers, underwent a clinical examination that included duplex ultrasonography in 3 vein segments in both legs to determine the presence and severity of venous reflux. Subjective perception of lower limb symptoms of CVI and the effect of leg problems on the ability to perform normal ADLs are assessed by means of a self-administered questionnaire. Most of the respondents have some CVI symptoms, with women being 1.5 to 3 times as likely as men to report leg symptoms. The risk of developing the most frequent subjective symptoms such as heaviness and tiredness in the legs is not statistically significantly different for younger subjects compared with older subjects. Advanced age is considered to be a relevant risk factor only for heat sensation and swollen legs. Persons living in southern Italy are at higher risk of almost all lower limb symptoms. Results of duplex ultrasonography performed on 3875 subjects show that fewer than 1 in 5 young persons, regardless of sex, manifest some degree of venous reflux (primarily mild symptoms). The risk of developing venous incompetence increases rapidly with age until it triples among subjects 50 years and older. Adjusting for all other factors, men are on average 1.5 times as likely as childless women to have venous reflux, and the risk increases in the case of family history of CVI or (among women) in the case of past pregnancies. More women than men report that their leg problems affect their ADLs. Pregnancy and living in the south contribute to a reduction in the ability to perform most heavy housework. Although milder lower limb symptoms such as evening heaviness and tiredness in the legs may begin early in life, venous reflux and related symptoms of heat sensation and swollen legs become more pronounced with age, and their severity can be disabling for those afflicted.

Visceral aortic patch aneurysm after thoracoabdominal aortic repair : Conventional vs hybrid treatment

OBJECTIVE Visceral aortic patch (VAP) aneurysm repair following thoracoabdominal aortic aneurysm (TAAA) open treatment carries high morbidity and mortality rates. The aim of this study is to compare the outcomes of our series of patients who underwent redo VAP aneurysm open surgery (conventional group) with a selected group of high-risk patients who underwent, in the same time period from 2001-2007, an alternative hybrid surgical and endovascular approach (hybrid group). METHODS Conventional group: Twelve patients (11 males, median age 71.5 years, range, 65 to 77 years) underwent VAP aneurysm (median maximum diameter 62 mm, range, 52 to 75 mm) repair with re-inclusion technique via redo thoracophrenolaparotomy or bilateral subcostal laparotomy. Reimplantation of a single undersized VAP or separate revascularization of one or more visceral arteries was performed. Hybrid group: Seven patients (5 males, median age 70 years, range, 63 to 78 years) defined as at high risk for conventional surgery having American Society of Anesthesiology (ASA) class 3 or 4 associated with a preoperative forced expiratory volume in 1 second (FEV1) <50% or an ejection fraction <40%, underwent VAP aneurysm (median maximum diameter 73 mm, range, 62 to 84 mm) repair via median laparotomy, visceral arteries rerouting, and VAP aneurysm exclusion using commercially available thoracic aortic endografts. RESULTS Conventional group: Perioperative mortality was 16.7% and major morbidity 33.3%. One perioperative anuria was successfully treated with bilateral renal artery stenting. No paraplegia or paraparesis were observed. At a median follow-up of 2.3 years (range, 1.6-7 years), we observed one case of peri-graft fluid collection with sepsis at postoperative day 46 requiring surgical drainage and prolonged antibiotic therapy and one case of renal failure at day 68 requiring permanent hemodialysis. Hybrid group: perioperative mortality was 14.3% and major morbidity 28.6% with one case of transient delayed paraplegia. At a median follow-up of 1.9 years (range, 0.3-6.8 years), we observed one case of late pancreatitis (46 days postoperatively) resolved with pharmacologic treatment and one death due to an acute visceral grafts thrombosis (78 days postoperatively). We did not observe other procedure-related deaths or complications, VAP aneurysm growth, endoleak, and endograft migration. CONCLUSION Hybrid repair is clearly a feasible alternative to simple observation for patients unfit for redo VAP aneurysm open surgery. However, despite our promising early results, new mid-term specific procedure-related complications have been observed and a widespread use of this technique should be currently limited until longer-term follow-up is available.

Endovascular Stenting for the Nutcracker Phenomenon

PURPOSE To present a case highlighting the efficacy of stent implantation for left renal vein (LRV) entrapment, otherwise known as the nutcracker phenomenon. CASE REPORT A 17-year-old boy presented with a history of gross hematuria and left flank pain. Magnetic resonance angiography documented compression of the LRV between the superior mesenteric artery and aorta. A Memotherm stent was successfully placed across the LRV to restore adequate luminal flow after a Wallstent failed to adequately span the narrowed segment. Spiral CT angiography at 6 months confirmed LRV patency; the patient remains asymptomatic and free of hematuria at 12 months. CONCLUSIONS Endovascular stenting for the nutcracker phenomenon is safe and effective and may represent a valuable approach for lessening the morbidity of surgical procedures.

The Risk of Spinal Cord Ischemia during Thoracic Aorta Endografting

Spinal cord ischemia (SCI) is a devastating complication of thoracic aortic surgery and its physiopathology is still poorly understood. Endovascular treatment with stentgrafts for the thoracic aorta (TEVAR) has significantly reduced the morbidity associated to thoracotomy and aortic cross clamping, but the incidence of SCI is still not negligible. We believe that TEVAR provides an opportunity to improve the knowledge of this devastating complication, since it removes the background noise of aortic cross-clamping and intercostal artery reimplantation. Management of thoracic aorta pathology with endovascular aortic repair had reduced in-hospital mortality, post-operative morbidity and recent series have reported encouraging midterm results. However the incidence of immediate and delayed SCI ranges from 0% and 12% (Table I). The results of three multicenter investigational trials for FDA approval of different thoracic endografts have been recently published with rates of SCI ranging from 2.8% to 8.7% (1-3) (Table II). Moreover these trials fail to demonstrate any statistically significant difference in the incidence of SCI between TEVAR and open repair.

Severe Vascular Complication after Implantation of a Three-Piece Inflatable Penile Prosthesis

We report a case of acute arterial ischemia and deep venous thrombosis due to compression of the external iliac vein and artery by the reservoir of a three-piece inflatable penile prosthesis.