Fabrizio Masciello

Secondary Procedures Following Iliac Branch Device Treatment of Aneurysms Involving the Iliac Bifurcation: The pELVIS Registry:

Purpose: To evaluate the incidence and reasons for secondary procedures in patients treated with iliac branch devices (IBDs) for isolated iliac aneurysm or aortoiliac aneurysms involving the iliac bifurcation. Methods: Between January 2005 and December 2015, 575 surgical-high-risk patients (mean age 72.0±8.4 years; 558 men) with isolated iliac aneurysms (n=79) or aortoiliac aneurysms involving the iliac bifurcation (n=496) were treated with placement of 650 ZBIS or Gore IBDs (75 bilateral) in 6 European centers. The primary outcome was procedure-related reinterventions for occlusion or high-grade (>70%) stenosis of the bridging device, occlusion of the ipsilateral common or external iliac artery (EIA), type I/III endoleak, rupture, or infection following IBD implantation. Clinical and radiological data were analyzed based on preset definitions of comorbidities, aneurysm morphology, intraoperative variables, and follow-up strategies. Results: Nine (1.6%) reinterventions were performed within 30 days for occlusion or endoleak. Among 10 (1.5%) occluded EIAs ipsilateral to a deployed IBD, 6 underwent a reintervention with additional stent placement after thrombolysis (n=4) or a femorofemoral or iliofemoral crossover bypass (n=2). Three of 14 patients with early type I endoleak had a reintervention for an insufficient proximal sealing zone (stent-grafts in 2 common iliac arteries and 1 bifurcated endograft). Mean clinical and radiological follow-up were 32.6±9.9 and 29.8±21.1 months, respectively. Forty-two (7.3%) patients underwent reinterventions in the follow-up period. The overall postoperative reintervention rate was 8.9%. Both external and common iliac segments occluded in 30 (4.6%) IBDs; 2 patients had a crossover bypass and 14 were treated with endovascular techniques. In the other 14 patients, no specific treatment was performed. Seven (1.2%) patients with isolated EIA occlusion were treated during follow-up. Nineteen of the overall 28 patients with type I endoleak underwent endovascular repair. The other 9 were under radiological surveillance due to less significant (<5 mm) sac increase. No reintervention was performed to recanalize 11 (1.6%) occluded internal iliac arteries. Conclusion: Midterm experience with placement of IBDs is associated with a low incidence of secondary procedures due to type I endoleaks and occlusions. The main reasons for reinterventions seem to be short proximal sealing zone and poor conformability of the ZBIS device in elongated EIAs.

A Matched Case-Control Study on Open and Endovascular Treatment of Popliteal Artery Aneurysms

Objective: To compare early and late results of open and endovascular management of popliteal artery aneurysm in a retrospective single-center matched case-control study Methods: From 1981 to 2015, 309 consecutive interventions for popliteal artery aneurysm were performed in our institution, in 59 cases with endovascular repair and in 250 cases with open repair. Endovascular repair was preferred in older asymptomatic patients, while open repair was offered more frequently to patients with a thrombosed popliteal artery aneurysm and a poor run-off status. A one-to-one coarsened exact matching on the basis of the baseline demographic, clinical, and anatomical covariates significantly different between the two treatment options was performed and two equivalent groups of 56 endovascular repairs and open repairs were generated. The two groups were compared in terms of perioperative results with χ2 test and of follow-up outcomes with the Kaplan–Meier curves and log-rank test. Results: There were no differences between the two groups in terms of perioperative outcomes. Median duration of follow-up was 38 months. Five-year survival rates were 94% in endovascular repair group and 89.5% in open repair group (p = 0.4, log-rank 0.6). Primary patency rates at 1, 3, and 5 years were 81%, 78%, and 72% in endovascular repair group and 82.5%, 80%, and 64% in open repair group (p = 0.8, log-rank 0.01). Freedom from reintervention at 5 years was 65.5% in endovascular repair group and 76% in open repair group (p = 0.2, log-rank 1.2). Secondary patency at 1, 3, and 5 years was 94%, 86%, and 74% in endovascular repair group, and 94%, 89%, and 71% in open repair group, respectively (p = 0.9, log-rank 0.01). The rates of limb preservation at 5 years were 94% in endovascular repair group and 86.4% in open repair group (p = 0.3, log-rank 0.8). Conclusion: Open repair and endovascular repair of popliteal artery aneurysms provided in this retrospective single-center experience similar perioperative and follow-up results in equivalent groups of patients.

IF12. The Influence of the Initial Diameter of the Aneurysm on Early and Long-Term Outcomes of Surgical Repair of Popliteal Artery Aneurysms

Objective: Vascular graft infections (VGIs) lead to increased morbidity and mortality, and elderly and comorbid patients are often affected. Negative pressure wound therapy (NPWT) is increasingly used for VGI, and some authors even advocate that a better surgical treatment option is NPWT, débridement, and graft preservation compared with more aggressive approaches in case of VGI with intact anastomosis (Samson III infection). We aimed to assess the effect of NWPT in a large cohort of patients with VGI. Methods: Participants of the prospective Vascular Graft Infection Cohort Study (VASGRA) with vascular surgery between March 2013 and March 2017 were included. Observation time was calculated from the end of surgical treatment after diagnosis of VGI to the end of antimicrobial therapy (cure of infection) or last follow-up, whichever occurred first. Patientand procedure-related variables were assessed by NPWT status (yes/no), location of VGI (aortoiliac, thoracic, or infrainguinal), or surgical procedure (débridement and retention of graft; partial or total explantation of graft) using nonparametric tests. We performed Kaplan-Meier curves and univariable and multivariable Cox proportional hazards regression models. Results: A total of 175, predominantly male (77%) patients with a median age of 67 years contributed to the analysis. Thereof, only 15 patients (8.3%) died of VGI after a follow-up time of 2.2 years. A surgical procedure was performed in 145 of 175 (83%) patients. The graft could be retained and débrided in 78 of 145 (54%) patients, whereas 67 (46%) patients had a partial (n 1⁄4 12) or complete graft excision (n 1⁄4 55). NPTW therapy showed an association with cure of infection (Fig) in patients with infrainguinal NPWT treatment (adjusted hazard ratio [aHR], 3.42; 95% confidence interval [CI], 1.37-8.60]; P 1⁄4 .009) and female sex (aHR, 1.74; 95% CI, 1.02-2.97; P 1⁄4 .042). There was no association of cure with NPWT for thoracic (aHR, 0.49; 95% CI, 0.13-1.85; P 1⁄4 .296) or abdominal VGI (aHR, 1.38; 95% CI, 0.57-3.34; P 1⁄4 .471). Conclusions: Multistaged NPWT treatment for downgrading of the infections was associated with a much lower VGI mortality than before.

IP191. Bare-Metal Stent and Covered Stent in the Management of Infrainguinal Arterial Obstructive Disease: A Case-Control Study∗

Objective: The current “gold standard” for diagnosis of peripheral artery disease (PAD) is ankle-brachial pressure index (ABI). PAD diagnosis is complicated by vascular calcification, which causes stiff vessels and may falsely elevate ABI. Few studies have used peripheral calcium score (PCS) in lower extremity arteries to measure PAD burden, and no studies have compared the diagnostic value of PCS with ABI. The primary aim of this study was to describe the association of PCS with continuous ABI measurements and categories of ABI in a retrospective cohort design. Methods: We identified 50 patients with PAD who underwent both computed tomography angiography and ABI measurements. ABI measurements were divided into categories based on PAD severity: severe (<0.5), moderate (0.5-0.9), normal (0.9-1.4), and noncompressible (>1.4). We evaluated runoff computed tomography angiograms that imaged from the abdominal aorta through the distal lower extremities and determined total calcium volume of plaques with density >130 HU and area >1 mm from the infrarenal abdominal aorta to the foot using TeraRecon (Foster City, Calif) software by two independent readers (intraclass correlation 99%). We explored the relationship between ABI and PCS using multiple linear regression and analysis of covariance while adjusting for age, race, smoking status, hypertension, hyperlipidemia, type 2 diabetes, and chronic kidney disease. Results: We found that ABI was inversely associated with PCS in linear regression (P < .01; Fig 1). Differences in mean PCS were also statistically significant across ABI categories (F(3,29) 1⁄4 5.03; P 1⁄4 .01; Fig 2). The mean PCS was 11,269.5 mm (standard deviation [SD], 10,519.4 mm) in patients with ABI <0.5, 4360.8 mm (SD, 3845.8 mm) in ABI 0.5 to 0.9, 3213.8 mm (SD, 4187.5 mm) in ABI 0.9 to 1.4, and 2452.3 mm (SD, 1070.3 mm) in ABI>1.4. Across subgroups, the mean PCS was significantly different for ABIs <0.5 and 0.5 to 0.9 (P 1⁄4 .02), <0.5 and >1.4 (P < .001), 0.5 to 0.9 and >1.4 (P 1⁄4 .04), and 0.9 to 1.4 and >1.4 (P 1⁄4 .05). Interestingly, the percentage of tibial calcium score relative to overall PCS was much lower in severe PAD (ABI <0.5), 0.03%, vs noncompressible PAD (ABI >1.4), 35.7% (P 1⁄4 .02). Conclusions: ABI values were inversely associated with PCS, and mean PCS was significantly higher in severe PAD (ABI <0.5). Mean PCSmay be a valid measure of PAD severity, and percentage of tibial calcium may help quantify PAD burden in noncompressible vessels. Our study serves as proof of concept for the development of a comprehensive PCS system to diagnose and to evaluate PAD severity, particularly in high-risk subpopulations in which noninvasive studies may be unreliable.

A Propensity Matched Comparison for Open and Endovascular Treatment of Post-carotid Endarterectomy Restenosis

OBJECTIVES To compare results of open and endovascular management of post-carotid endarterectomy (CEA) restenosis. METHODS This was a retrospective single centre matched case control study. From 2005 to 2015, 148 consecutive interventions for post-CEA restenosis were performed: 80 cases received carotid artery stenting (CAS) and 68 cases received redo CEA. Propensity score based matching was performed in a 1:1 ratio to compare outcomes. Coronary artery disease, degree of the carotid restenosis, timing of the re-intervention with respect to the primary intervention (greater or less than 24 months) and the presence of ipsilateral brain lesions were the covariates included in the matching. Peri-operative outcomes were analysed with χ2 tests, while late results were estimated by Kaplan-Meier methods. RESULTS After propensity matching, 32 CAS interventions were matched with 32 redo CEAs. There were no peri-operative deaths or strokes. Cranial nerve palsy occurred in seven patients in the redo CEA group. Median duration of follow-up was 36 months (interquartile range 24-60; range 6-120). The estimated 5 year survival rate was 94% in the CAS group and 72% in the redo CEA group (p=.1, log rank 2.4). There were no significant differences between the groups in terms of stroke free survival. In the CAS group, no severe restenosis were found, while in the redo CEA group eight patients had severe restenosis or occlusion of the operated carotid artery. Freedom from secondary restenosis at 4 years was 100% in the CAS group and 72.5% in the redo CEA group (p=.005, log rank 7.9). The corresponding figures in terms of freedom from secondary re-intervention were 100% and 83%, respectively (p=.02, log rank 4.8). CONCLUSIONS CAS and redo CEA in patients with post-CEA restenosis provided similar peri-operative results in a sample of equivalent patients. CAS patients had better follow-up results in terms of secondary restenosis and re-interventions. Further analysis is required with a larger number of patients and a longer follow-up time.