Felice Pecoraro

Chimney and Periscope Grafts Observed Over 2 Years After Their Use to Revascularize 169 Renovisceral Branches in 77 Patients With Complex Aortic Aneurysms

Purpose To evaluate the performance of periscope and/or chimney grafts (CPGs) in the endovascular treatment of pararenal or thoracoabdominal aneurysms using off-the-shelf devices. Methods Between February 2002 and August 2012, 77 consecutive patients (62 men; mean age 73±9 years) suffering from pararenal aortic (n=55), thoracoabdominal (n=16), or arch to visceral artery aneurysms (n=6) were treated with aortic stent-graft implantation requiring chimney and/or periscope grafts to maintain side branch perfusion. CPGs were planned in advance and were not used as bailout. A standardized follow-up protocol including computed tomographic angiography, laboratory testing, and clinical examination was performed at 6 weeks; 3, 6, and 12 months; and annually thereafter. Results Technical success was achieved in 76 (99%) patients; 1 branch stent-graft became dislocated from a renal artery, which could not be re-accessed. Overall, 169 target vessels (121 renal arteries, 30 superior mesenteric arteries, 17 celiac trunks, and 1 inferior mesenteric artery) were addressed with the chimney graft configuration in 111 and the periscope graft configuration in 58. In total, 228 devices were used for the CPGs: 213 Viabahn stent-grafts and 15 bare metal stents. Over a mean 25±16 months (range 1–121), 9 patients died of unrelated causes. Nearly all (95%) of the patients demonstrated a decreased or stable aneurysm size on imaging; there was a mean 13% shrinkage in aneurysm diameter. Twenty patients had primary type I/III endoleaks at discharge; in follow-up, only 3 of these were still present (no secondary or recurrent endoleaks were noted). Additional endovascular maneuvers were required for CPG-related complications in 13 patients from intervention throughout follow-up. Overall, 4 CPGs occluded (98% target vessel patency); no stent-graft migration was observed. Renal function remained stable in all patients. Conclusion In this series, the use of CPGs has proven to be a feasible, safe, and effective way to treat thoracoabdominal and pararenal aneurysms with maintenance of blood flow to the renovisceral arteries. Nearly all of the aneurysms showed no increase in diameter over a >2-year mean follow-up, which supports the midterm adequacy of the CPG technique as a method to effectively revascularize branch vessels with few endoleaks or branch occlusions.

Outpatient endovascular aortic aneurysm repair: experience in 100 consecutive patients.

Objectives:To present the safety, feasibility, costs, and patient satisfaction of outpatient endovascular aneurysm repair (EVAR). Background:Our experience in more than 1000 patients indicated that in technically uncomplicated EVAR procedures, the only need for hospitalization was for access vessel complications (bleeding or occlusion) requiring secondary procedures. These complications could always be identified within the first 3 hours after EVAR. Methods:Two-center retrospective analysis of prospectively gathered data on 100 consecutive elective outpatient EVAR cases (Outpt EVAR). Inclusion criteria for Outpt EVAR were as follows: asymptomatic clinical state, informed consent, travel time to the hospital if readmission was required of less than 60 minutes, adult observer assistance for the first 24 hours, and a technically uncomplicated EVAR procedure. EVAR was mostly performed under local anesthesia and with percutaneous access. Patients were discharged home after 4 to 6 hours of observation and checked the next morning and on the fifth postoperative day in the outpatient clinic. Results:From 104 patients selected, 4 (3.8%) preferred primary hospitalization and were excluded from further analysis. Four patients (4%) with access vessel complications required additional procedures and had to be hospitalized overnight. The 30-day readmission rate was 4% (4), all due to access vessel stenosis (2) or false aneurysm (2). There was no 30-day mortality. From the 96 outpatients who completed Outpt EVAR, 93 (97%) would undergo Outpt EVAR again and would recommend it to others. Cost comparison showed in 42 matched contemporary patients treated with just a standard stent graft that costs were significantly lower in 21 Outpt EVAR patients than in 21 inpatient EVAR. Conclusions:Elective Outpt EVAR can be performed safely, provided certain criteria are fulfilled and specific precautions are taken. In this series, Outpt EVAR morbidity was minimal, especially delirium common in elderly patients recovering from inpatient vascular surgery and nosocomial infections did not occur. Finally, patient satisfaction was high and costs were less than with standard inpatient EVAR.

Efficacy of TachoSil ® patches in controlling Dacron suture-hole bleeding after abdominal aortic aneurysm open repair

PurposeThe aim of this study is evaluate the efficacy of TachoSil® patches in controlling suture-hole bleeding after elective infrarenal abdominal aortic aneurysm (AAA) replacement with Dacron graft.Materials and methodsPatients undergoing elective replacement of infrarenal AAA with Dacron grafts were prospectively randomized to TachoSil® patches (Group I) or standard compression with surgical swabs (Group II).We evaluated time to haemostasis, blood loss during the operation, blood loss after cross-clamp removal, duration of operation, drain volume, requirement for blood transfusion and surgeons rating of efficacy.ResultsTwenty patients were randomized (10 patients in each treatment Group). The mean time to haemostasis was 264 ± 127.1 s (range: 180-600 s) in Group I and 408 ± 159.5 s (range: 120-720 s) in Group II (p = 0.026); mean blood loss during the operation was 503.5 ± 20.7 cc (range: 474-545 cc) in Group I and 615.7 ± 60.3 cc (range: 530-720 cc) in Group II (p < 0.001); mean blood loss after cross-clamp removal was 26.5 ± 4 g (range: 22-34 g) in Group I and 45.4 ± 4.6 (range: 38-52 g) in Group II (p < 0.001) and mean drain volume was 116.7 ± 41.4 cc (range: 79-230 cc) in Group I and 134.5 ± 42.8 cc (range: 101-250 cc) in Group II (p = 0.034). There were no serious adverse events associated with use of TachoSil® patches.ConclusionFor patients undergoing aortic reconstruction with Dacron grafts, TachoSil® patches were found to be safe and effective for the control of suture-hole bleeding.

A clampless and sutureless aortic anastomosis technique using an endograft connector for aortoiliac occlusive disease in which the aorta cannot be clamped or sewn due to calcification or scarring

Bypass surgery in aortoiliac or aortofemoral occlusive disease can be technically demanding and hazardous due to huge calcifications and/or patient co-morbidities. We report about mid-term results of a telescoping sutureless aortic anastomosis technique using endografts as connectors to address such challenging situations. This is a single-center experience (2004–2011) in seven patients (63 ± 6 years) requiring aortoiliac (three) or aortofemoral (four) bypass surgery. In six cases, an aortic stent graft was telescoped into the infrarenal aorta and partly deployed within the aorta and partly outside the aorta. In the first case, a bifurcated stent graft was deployed and the iliac legs were prolonged extra-anatomically with surgical grafts to reach the femoral bifurcation. In the following five cases, a tapered tubular stent graft was deployed through the aortic wall, landing inside a bifurcated surgical graft that was extra-anatomically connected to the iliac or femoral arteries. In the last case, which presented a hostile abdomen and high-risk for extensive surgery, a similar technique was used, but on the iliac artery level. In that case, an iliac stent graft re-loaded ‘upside down’ was deployed through the left common iliac wall, landing distally inside a hand-made 10 × 10 mm bifurcated surgical graft that was extra-anatomically connected to the left external iliac artery and to the right femoral artery. The distal anastomoses on the seven cases were performed either with running sutures (ten) or with VORTEC (four). Telescoping aortic and/or iliac anastomosis was successful in all patients. There was no perioperative mortality. One patient developed postoperative hyperperfusion of the left leg and necessitated fasciotomy. During a mean follow-up of 1.8 ± 2 years (minimum: 270 days, maximum: 7.1 years), all of the grafts remained patent and there was neither stent-graft migration nor stenosis on the level of the aortic or iliofemoral connection. One patient showed disease progression and required percutaneous transluminal angioplasty on the external iliac artery during follow-up. The uneventful perioperative course in these seven patients, with a follow-up of up to six years, underscores that this new technique can be considered in patients with aortoiliac or aortofemoral occlusive disease and in whom clamping and/or anastomosis is expected to be cumbersome or impossible.

Chimney and Periscope Grafts to Facilitate Endovascular Treatment of Aortic Transection in a Patient With Aberrant Right Subclavian Artery

Purpose To report the use of parallel grafts to extend the proximal landing zone for stent-graft repair of aortic transection involving an aberrant right subclavian artery (ARSA). Case Report A 28-year-old patient was referred for treatment of traumatic aortic transection with contained rupture at the level of an ARSA. Immediate thoracic endovascular aortic repair (TEVAR) was planned because of hemodynamic instability. To achieve rapid sealing and maintain perfusion to both subclavian arteries, a chimney stent to the left subclavian artery (LSA) and a periscope stent-graft to the ARSA were deployed successfully. After surgical repair of all fractures, the patient was discharged 1 month after the initial injury in good condition. Imaging follow-up at 10 months showed a stable repair, patent parallel grafts, and no complications. Conclusion TEVAR with chimney and periscope grafts proved to be a safe and quick treatment for a patient requiring ARSA repair in acute aortic transection. This technique maintained blood flow to the ARSA and LSA in a totally endovascular approach, which could be very valuable in transection cases where bypass surgery to supra-aortic branches is compromised or deemed challenging due to thoracic wall and/or neck trauma. Parallel grafting can be a valuable tool to address any acute aortic pathology as it can be performed with off-the-shelf devices.

Acute aortic dissection: a case report showing penetrating thoracic aortic ulcer and infrarenal aortic rupture.

An acute aortic syndrome with simultaneous presence of a penetrating aortic ulcer, an intramural haematoma, a thoracic aortic dissection and an abdominal aortic aneurysm rupture has not previously been reported. Herein, we describe our experience with a patient treated by endovascular means with an 8-year follow-up.

Endovascular Treatment Options for Complex Abdominal Aortic Aneurysms

PURPOSE To report short-term and midterm outcomes of endovascular aneurysm repair (EVAR) of complex aneurysms requiring revascularization of visceral arteries. MATERIALS AND METHODS Prospective data were collected from patients deemed unsuitable for conventional EVAR and conventional surgery who were treated with different endovascular approaches according to the clinical presentation of the aneurysm. Custom-made fenestrated endovascular aneurysm repair (CM f-EVAR) was used in the elective setting, homemade fenestrated endovascular aneurysm repair (HM f-EVAR) or HM f-EVAR combined with chimney endovascular aneurysm repair (ch-EVAR) was used in the emergent setting in patients with hemodynamic stability, and ch-EVAR was used in unstable cases. The study included 34 consecutive patients. Primary outcomes measured were perioperative mortality and morbidity, renal function impairment (RFI), target vessel patency, and survival at mean follow-up. RESULTS In the CM f-EVAR group (7 of 34 patients; 20.6%), an intraoperative type III endoleak (1 of 7 patients; 14%) sealed spontaneously. At 8.9 months of follow-up, 1 (1 of 7 patients; 14%) death and 1 (1 of 7 patients; 14%) episode of transient RFI were documented. Visceral vessel patency rate was 95.2%. In the HM f-EVAR group (4 of 34 patients; 11.7%) and the combination of HM f-EVAR and ch-EVAR group (3 of 34 patients; 8.8%), no complications were observed at 17.3 months of follow-up. In the ch-EVAR group (20 of 34 patients; 58.8%), visceral patency was 95% at 30.9 months of follow-up. Two cases of transient RFI and 2 cases of permanent RFI were registered (2 of 20 patients; 10%). One asymptomatic renal artery branch occlusion was observed at 11 months of follow-up. No endoleaks were documented. CONCLUSIONS Endovascular aneurysm repair techniques including CM f-EVAR, HM f-EVAR or HM f-EVAR in combination with ch-EVAR, and ch-EVAR are valid tools to maintain blood flow in visceral arteries during treatment of complex aortic aneurysms. The proposed interventional protocol based on clinical presentation was feasible in all cases.

A New Off-Pump Hybrid Open and Endovascular Repair to Treat Ductus Botalli and Ascendens Aneurysms

To report a combined ascending aorta and aortic arch hybrid repair, we performed off-pump with no aortic graft replacement. A 65-year-old man, developing progressive recurrent laryngeal nerve paralysis, underwent a computed tomography (CT) angiography detecting nonpatent residual ductus Botalli aneurysm and ascending aorta aneurysm. Due to severe multimorbidities, a less-invasive alternative was elaborated. In a first step, appropriate proximal landing zone for aortic stent grafting was achieved by ascending aorta diameter reduction, with epiaortic wrapping, and debranching the supra-aortic trunks. In the second step, endovascular stent grafts were deployed from proximal ascending aorta to descending aorta, excluding the ductus Botalli aneurysm. Six-month follow-up CT shows ductus Botalli aneurysm exclusion, stable stent graft position, and ascending diameter and patent and stenosis-free supra-aortic grafts. This case supports this alternative treatment to open aortic repair under circulatory arrest and deep hypothermia, especially in those patients considered unfit for such invasive treatment.

Popliteal Artery Aneurysm Repair in the Endovascular Era: Fourteen-Years Single Center Experience

Abstract To compare outcomes of popliteal artery aneurysm (PAA) repair by endovascular treatment, great saphenous vein (GSV) bypass, and prosthetic bypass. Single center retrospective analysis of patients presenting PAA from 2000 to 2013. Patients were divided into endovascular treatment (group A); GSV bypass (group B); and prosthetic graft bypass (group C). Outcomes were technical success, perioperative mortality, and morbidity. Survival, primary and secondary patency, and freedom from reintervention rate were estimated. Differences in ankle-brachial index (ABI), in-hospital length of stay (InH-Los), red blood cell (RBC) transfusion, and limb loss were reported. Mean follow-up was 49 (median: 35; 1–145; SD 42) months. Sixty-seven patients were included; 25 in group A, 28 in group B, and 14 in group C. PAA was symptomatic in 23 (34%) cases. Technical success was 100%. No perioperative death occurred. Three (4.5%) perioperative complications were reported with no significant difference between groups (P = 0.866). Five-years estimated survival was 78%. Estimated 5-years primary patency for groups A, B, and C was 71%, 81%, and 69%, respectively (P = 0.19). Estimated 5-years secondary patency for groups A, B, and C was 88%, 85%, and 84% (P = 0.85). Estimated 5-years freedom from reintervention for groups A, B, and C was 62%, 84%, and 70%, respectively (P = 0.16). A significant difference between preoperative ABI versus postoperative ABI was observed (P = 0.001). InH-LoS was significantly shorter in group A (P < 0.001). RBC transfusions were required significantly less in group A when compared to group C (P = 0.045). Overall limb salvage was achieved in all but 1 patient. PAA repair has good early and long-term outcomes with different treatment options. Endovascular treatment was not inferior to surgical repair with a reduced InH-LoS and RBC transfusion. It can be successfully employed even in nonelective setting. A randomized controlled trial with long-term follow-up and appropriate patient inclusion criteria is necessary to compare these 3 treatment options.

Endograft connector technique to treat popliteal artery aneurysm in a morbid obese patient.

Surgical repair of popliteal artery aneurysm in morbid obese patients poses additional challenges. We report a morbid obese patient who had a 59 mm right popliteal artery aneurysm which was successfully treated with the endograft connector technique. This technique was used to perform the distal anastomosis of the below-knee femoro-popliteal bypass. A 10 mm Dacron graft was used as a main graft bypass and an 11 mm/10 cm stentgraft as endograft connector. Following the respective tunnel of the Dacron graft, an end-to-side proximal anastomosis was performed at distal femoral artery. The aneurysm exclusion was obtained through a proximal and a distal ligation. Postoperative duplex showed adequate bypass patency. Knee x-rays demonstrated no signs of stent kinking/fractures. The postoperative course was uneventful and the patient was discharged home on fourth day post operative. The six-month computed tomography scan and the 12-month duplex control showed a patent bypass with no signs of stenosis.