Gian Franco Fadda

Seven-Year Approach Evolution of the Aortoiliac Occlusive Disease Endovascular Treatment

BACKGROUND Endovascular treatment is now considered the first-line therapy for the aortoiliac occlusive disease (AIOD). We report our experience with the total endovascular treatment of infrarenal and pararenal aortoiliac occlusions and the 7-year approach evolution. METHODS A total of 22 patients underwent total endovascular treatment of AIOD from January 2008 to September 2014. Bare metal stents in kissing configuration were deployed in 9 cases, covered stents in kissing configuration in 9 patients and the aortic bifurcation reconstruction with the Y-guidewire configuration technique was performed in the last 4 patients. RESULTS Technical success was 100%. Perioperative mortality rate was 4.5%. ankle-brachial index improved from 0.49 ± 0.19 to 0.96 ± 0.05 at the right side and from 0.53 ± 0.17 0.98 ± 0.04 at the left side (P < 0.01). Mean follow-up was 39.5 months (range, 5-80 months). The primary patency rate was 95.2% at 1 year and 90.5% at 3 years, and the secondary patency rate was 95.2% at 1 year and 100% at 3 years. CONCLUSIONS Different stent types and configurations used for the aortoiliac endovascular treatment offer all the benefits of these materials for treatment on a case-by-case basis. The Y-guidewire configuration technique for the aortic bifurcation reconstruction may render the procedure more feasible. More cases and longer follow-up are necessary before the widespread use of this technique.

Familial Incidence of Abdominal Aortic Aneurysms

The rupture of an abdominal aortic aneurysms (AAAs) is associated with a mortality rate exceeding 50%. To reduce this figure it is necessary to increase the frequency of early diagnosis and elective surgery. Screening the general population for occult AAAs has proven cost ineffective. Only by identifying high-risk subgroups will screening programs be improved. The aim of this report was to investigate by ultrasonography the prevalence of previously unknown aortic dilatations among first-degree relatives (parents, siblings, and children) of patients operated on for AAAs. Ninety-one (52.6%) of the 173 living first degree-relatives of 51 patients who underwent AAA resection were submitted to an aortoiliac ultrasonographic examina tion to establish aortic diameter and morphology. There was at least 1 first-degree relative with an AAA (multiplex family) in 10 families (19.6%) before ultrasound screening. With ultrasound a previously unknown infrarenal aortic dilatation was detected in 14 subjects (9 men/5 women; 10 siblings and 4 children) of 12 different families. Specifically, these aortic dilatations consisted of 10 AAAs (diameters ranged from 2.6 to 4.3 cm) and 4 aortic blebs. These occult aortic dilatations were located in 50% of cases in the lower third of the infrarenal abdominal aorta. The cumulative incidence of multiplex families was 35.3%. This study suggests a familial tendency to have an important etiologic role in the formation of AAAs. Family screening of, above all, male siblings older than forty-five years will help identify occult AAAs and reduce the mortality rates associated with their rupture.

Aortic Arch and Descending Thoracic Aortic Saccular Aneurysms Treatment with Fenestrated Endograft and Chimney Technique for Aortic Branch Rescue

We report the case of a 76-year-old man presented with three saccular aneurysms at the aortic arch and descending thoracic aorta. A two-staged hybrid approach was performed. A left common carotid-to-left subclavian artery bypass and a custom-made fenestrated endograft were used for the two proximal aneurysms. The endograft deployment was complicated by the unadverted coverage of the left common carotid artery ostium, promptly corrected with the chimney technique. The endovascular treatment was completed with the third endovascular aneurysm exclusion 5 months after the first procedure to reduce the risk of spinal cord ischemia. Yearly follow-up computed tomography scan confirmed aortic arch and descending thoracic aorta aneurysms exclusion with supra-aortic vessels, bypass, and stent patency. Endovascular repair of the aortic arch aneurysm with a fenestrated endograft is safe and feasible in selected patients. Complications may be solved with total endovascular approach. Long term follow-up remains mandatory.

Novel Approach for Juxtarenal Aortic Occlusion Treatment: The Y-Guidewire Configuration for Aortic Bifurcation Reconstruction

Infrarenal aortic occlusion accounts for 3–8.5 % of aortoiliac occlusive disease with the juxtarenal form affecting [50 % of patients [1, 2]. TASC II guidelines recommend reconstructive surgery as the best treatment for juxtarenal aortic occlusion (JAO) [3]. Endovascular therapies, widely used for less complex lesions, actually are becoming an attractive option for JAO treatment, especially in patients considered at high risk for open surgery. Antegrade recanalization from the brachial access and retrograde angioplasty and stenting using bare stents from bilateral femoral accesses is the treatment strategy reported [4, 5]. Protective measures for the renal arteries, such as guidewires, filters, or balloons, become necessary when the distance between the ostium of the lower renal artery and the aortic occlusion is\2 cm [1, 4]. Goverde et al. [6] performed the covered endovascular reconstruction of aortic bifurcation (CERAB) technique for extensive aortoiliac occlusive disease with balloonexpandable covered stents to limit complications, such as dissection, arterial rupture, or embolization, and to prevent late intrastent restenosis. Antegrade recanalization and retrograde stenting were performed. We report a new approach to reconstruct the aortoiliac bifurcation using self-expandable covered stents: antegrade aortic and retrograde iliac recanalization and stenting with the Y-guidewire configuration. A 58-year-old man presented to our department with lower-limb rest pain. The patient was classified as American Society of Anesthesiology category III and New York Heart Association category III. The ankle–brachial index was 0.32 (right) and 0.28 (left). Computed tomography (CT) scan showed the JAO up to the iliac artery bifurcation, two right and one left renal arteries. The distance between the lower right renal artery (2.5-mm diameter) and the occluded aorta was 3 mm. To avoid open reconstruction, the patient was offered a less invasive endovascular procedure. Written informed consent was obtained before the procedure. Institutional Review Board approval was obtained before data collection. With the patient under local anesthesia, and after systemic heparinization was achieved, a 12F, 45 cm-long sheath (Flexor RB-RAABE; Cook Medical, Bloomington, IN) was placed through an open surgical brachial access. A 7F, 90 cm-long sheath (Destination Straight CCV; Terumo, Tokyo, Japan) was introduced into the suprarenal aorta, and preliminary angiography was performed (Fig. 1). Transbrachial recanalization was obtained using a 0.03500 hydrophilic, angled guidewire (Radiofocus Guide Wire, Terumo). Once the wire crossed the proximal cap, the Destination sheath was placed inside the proximal level of the occlusion to obtain a more stable position, thus decreasing the risk of thrombus mobilization. After successful recanalization, each femoral artery was punctured under fluoroscopic guidance. After placing the 7F, G. F. Fadda C. L. Di Angelo R. Borghesi M. Marino Vascular Surgery Unit, Department of Surgery, San Francesco Hospital, Via Mannironi 1, 08100 Nuoro, Italy e-mail: gffadda@gmail.com

Hybrid Endovascular Solutions for Supra-Aortic Vessels Extra-Anatomic Bypass Infection

The use of extra-anatomic bypasses for the hybrid repair of thoracic aortic pathologies should consider the risk of vascular graft infection. Graft infections at cervical level are extremely rare and are associated with high mortality and morbidity rates. We report 2 cases of infected extra-anatomic bypasses for supra-aortic vessels debranching treated with a hybrid approach: re-extra-anatomical bypass with the Viabahn Open Revascularization Technique (VORTEC) in the first patient and the EndoVAC approach in the second case. Endovascular techniques may offer bail-out solutions in a hybrid fashion to treat vascular graft infection in patients considered unfeasible for the conventional surgical repair, associated with appropriate antibiotic therapy.

Ruptured Thoracoabdominal Aneurysm Treatment With Modified Chimney Stent Graft

A 76-year-old woman presented with symptomatic contained-ruptured thoracoabdominal aneurysm at the level of the superior mesenteric artery (SMA) and the hepatic artery origin from the SMA. The chimney technique for celiac trunk, SMA, and right renal artery (periscope configuration) was performed. An endovascular leak from the distal landing zone of the SMA stent graft was treated using a second modified stent graft with the SMA branches preservation. The 18-month follow-up computed tomography angiography demonstrated the aneurysm exclusion, no endovascular leak, and visceral and renal arteries patency.

Complicated Fenestrated Endovascular Repair of a Pararenal Aortic Aneurysm.

We report the case of a 77-year-old man treated with a custom-made fenestrated endograft for pararenal aortic aneurysm repair. Fenestrations for the superior mesenteric and both the renal arteries and augmented anterior valley and/or scallop for the celiac trunk were performed. The procedure was complicated by the superior mesenteric artery stent-graft entrapment from the endograft delivery system release wires and total dislodgement into the endograft main body. Superior mesenteric artery restenting and displaced stent-graft removal completed the intervention. Fenestrated-endograft deployment should be performed by a team familiar with the device, deployment system, and bail out solutions.

From Aortouniiliac Bifurcated to Aortobisiliac Trifurcated Endograft for Hypogastric Artery Preservation during EVAR

An 81-year-old man presented with rapid enlargement of a 2-year known abdominal aortic and common iliac aneurysms. A hybrid approach to preserve both hypogastric arteries (HAs) was planned: a bifurcated endograft for the right aortoiliac axis, right femoral-to-left femoral artery bypass, and left external-to-internal iliac artery stent graft placement. Urethral stenosis requiring an epicystostomy rendered this approach not feasible. After left HA embolization, a bifurcated endograft was deployed for the abdominal aortic aneurysm exclusion. The endograft right limb was extended using a second bifurcated endograft for the ipsilateral aortoiliac axis. Surgical femoral accesses were used for the 2 bifurcated endografts and left HA embolization. Through the left brachial access, 2 stent grafts were used to preserve the right hypogastric artery revascularization. The 5-year follow-up computed tomography scan demonstrated complete aneurysm exclusion and HA patency.

Laparoscopic Transarterial Embolization of Type II Endoleak after Branched/Fenestrated Thoracoabdominal Aortic Aneurysm Endovascular Repair

Type II endoleak is the most frequent procedure-related complication during endovascular aneurysm exclusion. Actually, there is little controversy in the management of type I and III endoleak, while type II endoleak still generates conflicting reports about their timing and type of treatment. Currently, the intervention is needed only in case of sac enlargement but not in case of persistent endoleak alone. We report the case of a 77-year-old man treated with a custom-made branched/fenestrated endograft for a type III thoracoabdominal aortic aneurysm. A low-flow type II endoleak was detected at the end of the intervention, and a conservative approach was adopted. The sixth month follow-up computed tomography scan demonstrated a 6-mm aneurysm sac growth that required the type II endoleak management. The endoleak nidus, situated between the inferior mesenteric artery (IMA) and left renal artery stent graft, was embolized through the IMA punctured laparoscopically. IMA origin laparoscopic clipping completed the intervention. To our knowledge, this is a unique case in the literature. Type II endoleak management should be reserved to selected patients. The combination of different techniques may offer safe and feasible treatment options in complex aneurysms treated with advanced endovascular materials.

Endovascular repair of a proximal ilio-iliac arterio-venous fistula and distal pseudoaneurysm of the hypogastric artery 23 years after penetrating trauma

We report the treatment of a proximal ilio-iliac arterio-venous fistula and distal omolateral hypogastric artery pseudoaneurysm 23 years after incurring a gunshot wound in a 43-year old man presenting with lower back pain. No cardiac, pulmonary or omolateral lower limb alteration was observed. Endovascular exclusion of the arterio-venous fistula and pseudoaneurysm was performed, which included pseudoaneurysm embolization. Three procedure-related complications were registered. The follow-up at 12 months revealed stent grafts patency, pseudoaneurysm and fistula exclusion.