Giulio Barbiero

Strategies of endoleak management following endoluminal treatment of abdominal aortic aneurysms in 95 patients: how, when and why

PurposeThis study reviews, on the basis of our experience, the indications and options for treating endoleaks (EL) after endovascular repair of abdominal aortic aneurysms (AAA) by endografting.Materials and methodsNinety-five patients (M/F =92/3; mean age at time of operation 70.7±7.8 years) who underwent endovascular repair of infrarenal AAA between April 1997 and October 2004 were considered. All images of 420 pre-and postoperative computed tomography (CT) studies were reviewed.ResultsA total of 37 EL occurred in 33/95 patients (34.7%), four of whom had two EL of different types. Eighteen EL were treated, 16 by endoluminal treatment. Six EL were type I: 2 were treated by percutaneous transluminal angioplasty (PTA) and 4 by cuff deployment (2 proximal cuffs and 2 distal cuffs). Eight EL were type II: 2 were treated by PTA, 2 by cuff deployment, 1 by transcatheter coil embolisation of the inferior mesenteric artery, two by thrombin injection in the aneurysm sac and one underwent surgical conversion during an attempt to treat a concomitant type I EL. Finally, 2 EL were type III: 1 was treated by PTA and 1 by cuff deployment. Endovascular treatment was successful in 12/16 cases (75%), whereas 3/16 cases (18.8%) were converted to open surgery, and 1 patient died of AAA rupture the day after endovascular repair.ConclusionsEL is the most common complication after endovascular repair of AAA. In type I and type III EL, treatment is mandatory, whereas in type II (and type V) EL, treatment is indicated in the presence of AAA enlargement. Type IV EL generally disappear spontaneously. Endovascular repair is feasible and can be performed with different techniques according to EL aetiology, but it is not always decisive, and in some cases surgical conversion is required.RiassuntoObiettivoRevisionare, in base alla nostra esperienza, le indicazioni e le opzioni terapeutiche per il trattamento degli endoleak (EL) successivi al trattamento endovascolare degli aneurismi dell’aorta addominale (AAA) mediante endoprotesi (EP).Materiali e metodiSono stati considerati retrospettivamente 95 pazienti consecutivi (M/F=92/3; età media al momento dell’impianto 70,7±7,8 anni) sottoposti nel periodo aprile 1997-ottobre 2004 ad impianto di EP per esclusione di AAA infrarenale. Sono state revisionate le immagini di 420 esami TC eseguiti sia in fase preoperatoria che postoperatoria.RisultatiIn 33/95 (34,7%) dei pazienti si sono verificati complessivamente 37 EL, essendovi stati 4 pazienti con 2 EL di tipo diverso. Fra questi, 18 EL hanno richiesto trattamento, di cui 16 per via endovascolare. Sei EL erano di tipo I: 2 sono stati trattati con PTA e 4 con il posizionamento di cuffie (2 prossimali e 2 distali). Otto EL erano di tipo II: 2 sono stati trattati con PTA, 2 con il posizionamento di una cuffia iliaca, 1 con embolizzazione transcatetere dell’arteria mesenterica inferiore, 2 con iniezione di trombina all’interno della sacca aneurismatica e in un caso, associato anche ad EL di tipo I, nel tentativo di trattamento di quest’ultimo, si è ricorsi a conversione chirurgica. Infine 2 EL erano di tipo III: 1 è stato trattato con PTA e 1 con il posizionamento di una cuffia iliaca. Il tasso di successo tecnico è stato del 75% (12/16 EL), essendovi stata necessità di conversione chirurgica in 3/16 casi (18,8%) ed essendo un paziente deceduto il giorno successivo al trattamento endovascolare per rottura dell’AAA.ConclusioniL’EL rappresenta una delle complicanze più frequenti dopo trattamento endovascolare di AAA. Sono sempre candidati al trattamento gli EL graft-correlati (tipi I e III), mentre gli EL di tipo II (e tipo V) devono essere trattati solo se associati a crescita dimensionale dell’AAA. Gli EL di tipo IV solitamente si risolvono con regressione spontanea. Il trattamento endovascolare è possibile secondo diverse modalità in base all’eziologia dell’EL, ma non sempre è risolutivo e talvolta è necessario ricorrere alla conversione chirurgica.

Radiology for laparoscopic adjustable gastric banding: a simplified follow-up examination method.

Background:The aim of this study was to identify factors which allow a reliable, standardized and simplified approach for the radiologic follow-up of obese patients who have undergone surgery for laparoscopic adjustable gastric banding (LAGB) placement. Methods: A study was made of 370 consecutive single-contrast upper gastrointestinal series in 159 consecutive patients (122 women, 31 men; mean age 40.6 years; mean body weight 135.8 kg) who had undergone LAGB for morbid obesity and were symptomatic or had inadequate weight loss. The control group consisted of 38 subjects who had undergone LAGB, had satisfactory weight loss and were asymptomatic at follow-up. Results: Each gastric portion above the band was satisfactorily evaluated by measuring its vertical diameter. The optimal projection for measurement of stoma size was predicted before administration of the contrast agent and was achieved when the band was visualized in profile. The clinical pictures were not always related to stoma size. Surgical complications were gastric herniation (8 patients, twice in 1 patient, 5.7%), malpositioned band (1 patient, 1.6%), port twisting (13 patients, 8.2%), and disconnection or leakage of the device (8 patients, 5.0%). Conclusion: Essential criteria for the radiologic evaluation of LAGB are: position of port and tubing; stoma size; and volume of each upper gastric portion.

Percutaneous thrombin embolization of a pancreatico-duodenal artery pseudoaneurysm after failing of the endovascular treatment.

Pancreatico-duodenal artery (PDA) pseudoaneurysms are rare vascular conditions with high mortality rates after rupture and they are frequently secondary to pancreatitis, surgery, trauma or infection. Due to the high risk of rupture and bleeding, it is mandatory to treat all pseudoaneurysms, regardless of their size or symptomatology. First option of treatment is open surgical repair, but it has high mortality rate, especially in hemodynamically unstable patients. In the recent years, percutaneous ultrasonography (US)- or computed tomography-guided thrombin injection was proposed as an alternative method for treating visceral aneurysms and pseudoaneurysms, but few reports described this therapy in case of peri-pancreatic pseudoaneurysms. We present a rare case of pseudoaneurysm of the PDA in a patient with no previous history of pancreatitis nor major surgery but with an occlusive lesion of the celiac axis. To the best of our knowledge this is the first reported case of PDA pseudoaneurysm successfully treated in emergency by single transabdominal US-guided injection of thrombin after failed attempts of percutaneous catheterization of the feeding vessel of the pseudoaneurysm.

Metoclopramide unmasks potentially misleading contralateral suppression in patients undergoing adrenal vein sampling for primary aldosteronism.

Objective: As metoclopramide stimulates aldosterone secretion, we tested its usefulness in the assessment of lateralization of primary aldosteronism by adrenal vein sampling (AVS). Design: Prospective within-patient study in consecutive patients undergoing AVS for primary aldosteronism subtyping. Methods: We compared the diagnostic accuracy of baseline and postmetoclopramide lateralization index and relative (to cortisol) aldosterone secretion indices (RASI) for each adrenal gland with aldosterone-producing adenoma (APA) determined by the four corners criteria as the reference diagnosis. Results: We recruited 93 consecutive patients (mean age: 52 years; women 31%). Metoclopramide increased plasma aldosterone in the inferior vena cava and in both adrenal veins. The postmetoclopramide lateralization index was accurate in identifying APA, but did not increase diagnostic accuracy over baseline lateralization index, because the RASI increased similarly in both sides. Conversely, metoclopramide raised RASI to values more than 0.90 bilaterally in non-APA patients allowing accurate identification of factitious aldosterone suppression. In contrast, RASI was 0.90 or less in 48% contralateral to the tumor in APA patients. Regression analysis showed the APA patients with persistent suppression of RASI contralaterally showed a more florid primary aldosteronism phenotype. Conclusion: Metoclopramide does not enhance lateralization of aldosterone excess in APA, but consistently increased the value of RASI in non-APA cases, thus unmasking potentially misleading suppression of aldosterone. Postmetoclopramide RASI may therefore allow a more precise diagnosis when AVS can be achieved only unilaterally.

Morphological and functional modifications of the aneurysm-endograft complex following endoluminal treatment of abdominal aortic aneurysms

Purpose.The aim of the study was to evaluate quantitatively the main morphological changes of the abdominal aortic aneurysm (AAA)-endograft (EG) complex following endovascular repair of infrarenal AAA and to evaluate the functional consequences of these changes in terms of rate of complications (endoleaks and thrombosis). We also assessed whether these morphological and functional changes were related to the size of the AAA and to the type of EG used.Materials and methods.Eighty-five patients (M/F=82/3; mean age at time of operation 70.5±3.5 years, range 49.9–89.6 years) who underwent endovascular treatment of infrarenal AAA between April 1997 and October 2004 with a follow-up of at least 1 month were considered. All images of 408 preoperative and postoperative computed tomography (CT) studies were reviewed. Statistical analysis was performed with log-rank test on the 85 patients grouped according to AAA diameter <50 mm or ≤50 mm, and on 75 patients grouped according to EG device used (AneuRx, Talent or Excluder).Results.Morphological and dimensional changes involved the diameter (six cases) and length (14 cases) of AAA proximal neck, diameter (36 cases) and length (51 cases) of the aneurysm sac and shape of the stent-graft (47 cases). The prevalence of endoleaks was 37.6% whereas endoluminal thrombosis was observed in 27.1% of patients. AAA growth was significantly correlated (p=0.002) with the preprocedural diameter of the aneurysm sac whereas shrinkage was significantly correlated (p=0.0005) with the EG used.Conclusions.AAA growth was correlated with the diameter of the aneurysm sac while shrinkage was correlated with the EG used. During follow-up after endovascular repair, patients require careful evaluation of the morphological and dimensional features of the AAA and EG to promptly identify any changes that can anticipate major complications and even conversion to conventional surgery.

Intra-arterial thrombolysis of acute hand ischaemia with or without microcatheter: preliminary experience and comparison with the literature.

PurposeThis paper evaluates the indications, techniques, results, and complications of intra-arterial thrombolysis with or without a multihole microcatheter in three cases of acute hand ischaemia in comparison with the literature.Materials and methodsThree men (mean age 39 years) with symptoms and signs of acute hand ischaemia (i.e. pain, pallor, cyanosis, decreased motor or sensory function) were studied with Doppler ultrasound and selective arteriography, which demonstrated acute clotting of wrist and/or hand arteries. They therefore underwent intra-arterial thrombolysis with the administration of urokinase and vasodilators and heparin if necessary, with (n=2) or without (n=1) multihole microcatheters.ResultsIn all three cases, partial or complete recanalisation of the occluded arteries was achieved, with almost complete remission of clinical symptoms and good recovery of hand function.ConclusionsPercutaneous intra-arterial thrombolysis is an effective therapeutic approach in cases of acute hand ischaemia and is a valid alternative to surgical thrombectomy. Multihole microcatheters allow the thrombolytic agent to be distributed more evenly into the clot and may help to reduce reactive arterial spasm.RiassuntoObiettivoScopo del nostro lavoro è stato valutare indicazioni, tecnica, risultati e complicanze della procedura di trombolisi endoarteriosa senza o con microcatetere multiforato in 3 casi di lesioni ischemiche acute della mano e confrontarli con i dati della letteratura.Materiali e metodiTre pazienti maschi (età media 39 anni) con sintomi e segni di lesione ischemica acuta della mano (dolore, pallore, cianosi ungueale, deficit sensoriale e motorio) sono stati sottoposti dapprima ad esame eco-color doppler e, quindi, ad angiografia selettiva, portando alla identificazione di un’occlusione trombotica acuta di arterie del polso e/o della mano; pertanto sono stati sottoposti a trattamento trombolitico endoarterioso mediante somministrazione di urochinasi e di vasodilatatori, e, al bisogno, di eparina, con (2 casi) o senza (1 caso) microcatetere multiforato.RisultatiIn tutti e 3 i casi si è osservata una ricanalizzazione parziale o completa delle arterie precedentemente occluse con remissione pressoché completa della sintomatologia clinica e buon recupero funzionale.ConclusioniLa terapia trombolitica endoarteriosa percutanea rappresenta una valida opzione terapeutica nei casi di ischemia acuta della mano e costituisce una valida alternativa alla trombectomia chirurgica. Il microcatetere multiforato è un utile supporto che permette una più omogenea distribuzione dell’agente trombolitico all’interno del coagulo e può ridurre lo spasmo arterioso reattivo.

Macrolides for KCNJ5–mutated aldosterone-producing adenoma (MAPA): design of a study for personalized diagnosis of primary aldosteronism

Abstract Purpose: Aldosterone-producing adenoma (APA) is the main curable cause of endocrine hypertension cause of primary aldosteronism (PA) and it is in up to 66% of all cases investigated with adrenal vein sampling (AVS). Mutations in the KCNJ5 potassium channel involve up to 70% of APA and cause the most florid PA phenotypes. The recent finding that macrolide antibiotics specifically inhibit in vitro the altered function of mutated KCNJ5 channels has opened new horizons for the diagnosis and treatment of APA with KCNJ5 mutations in that it can allow identification and target treatment of PA patients harbouring a mutated APA. Thus, we aimed at investigating if clarithromycin and roxithromycin, two macrolides that potently blunt mutated Kir3.4 channel function in vitro, affect plasma aldosterone concentration in adrenal vein blood during AVS and in peripheral blood, respectively, in PA patients with a mutated APA. Methods and design: We designed two proof of concept studies. In study A: consecutive patients with an unambiguous biochemical evidence of PA will be exposed to a single dose of 250 mg clarithromycin during AVS, to assess its effect on the relative aldosterone secretion index in adrenal vein blood from the gland with and without APA. In study B: consecutive hypertensive patients submitted to the work-up for hypertension will receive a single oral dose of 150 mg roxithromycin. The experimental endpoints will be the change induced by roxithromycin of plasma aldosterone concentration and other steroids, direct active renin concentration, serum K+, systolic and diastolic blood pressure. Discussion: We expect to prove that: (i) clarithromycin allows identification of mutated APA before adrenalectomy and sequencing of tumour DNA; (ii) the acute changes of plasma aldosterone concentration, direct active renin concentration, and blood pressure in peripheral venous blood after roxithromycin can be a proxy for the presence of an APA with somatic mutations.

The subtyping of primary aldosteronism by adrenal vein sampling: sequential blood sampling causes factitious lateralization

Background: The pulsatile secretion of adrenocortical hormones and a stress reaction occurring when starting adrenal vein sampling (AVS) can affect the selectivity and also the assessment of lateralization when sequential blood sampling is used. We therefore tested the hypothesis that a simulated sequential blood sampling could decrease the diagnostic accuracy of lateralization index for identification of aldosterone-producing adenoma (APA), as compared with bilaterally simultaneous AVS. Methods and results: In 138 consecutive patients who underwent subtyping of primary aldosteronism, we compared the results obtained simultaneously bilaterally when starting AVS (t-15) and 15 min after (t0), with those gained with a simulated sequential right-to-left AVS technique (R ⇒ L) created by combining hormonal values obtained at t-15 and at t0. The concordance between simultaneously obtained values at t-15 and t0, and between simultaneously obtained values and values gained with a sequential R ⇒ L technique, was also assessed. We found a marked interindividual variability of lateralization index values in the patients with bilaterally selective AVS at both time point. However, overall the lateralization index simultaneously determined at t0 provided a more accurate identification of APA than the simulated sequential lateralization indexR ⇒ L (P = 0.001). Moreover, regardless of which side was sampled first, the sequential AVS technique induced a sequence-dependent overestimation of lateralization index. While in APA patients the concordance between simultaneous AVS at t0 and t-15 and between simultaneous t0 and sequential technique was moderate-to-good (K = 0.55 and 0.66, respectively), in non-APA patients, it was poor (K = 0.12 and 0.13, respectively). Conclusion: Sequential AVS generates factitious between-sides gradients, which lower its diagnostic accuracy, likely because of the stress reaction arising upon starting AVS.

LB02.07: EFFECT OF ACUTE DA2 DOPAMINERGIC RECEPTOR BLOCKADE ON PERFORMANCE OF ADRENAL VEIN SAMPLING FOR SUBTYPING OF PRIMARY ALDOSTERONISM.

Objective: As dopamine tonically inhibits aldosterone release via DA2 receptors, we hypothesized that acute DA2 blockade during adrenal vein sampling (AVS) might improve the assessment of lateralization of aldosterone excess in the subtyping of primary aldosteronism. Design and method: we prospectively investigated the acute effect of metoclopramide on the lateralization index [LI, defined as the ratio of aldosterone over cortisol plasma concentration (PAC:PCC) in the dominant over the PAC:PCC in the contralateral side] and on the relative aldosterone secretion index in adrenal vein blood [RI, defined as the ratio of plasma aldosterone concentration (PAC) in the adrenal vein over PAC in inferior vena cava (IVC), normalized by the ipsilateral Selectivity Index]. To this end we compared baseline and post-metoclopramide LI and RI values in 92 consecutive patients undergoing AVS from 2008 to 2014. As gold standard we used the diagnosis of aldosterone-producing adenoma (APA), based on pathology and follow-up data according to the four corners criteria. Results: Metoclopramide increased aldosterone in the IVC and in adrenal vein blood of both sides (p < 0.0001 for all). Even though post-metoclopramide LI provided an accurate identification of APA (AUC = 0.880, p = 0.0001 vs identity line; Youden Index >2.7, sensitivity 81%, specificity 83%), it showed no incremental diagnostic gain over baseline LI (p = 0.75 for ROC curves comparison). Metoclopramide also increased the RI (p < 0.001) both from the dominant and the non-dominant side [3.13 (2.53–4.33) to 8.76 (5.31–12.21); 0.91 (0.68–1.36) to 2.19 (1.61–3.23), respectively]. However, metoclopramide raised the RI on the APA side to values > 1.00 in all the 39 unequivocally diagnosed APA patients. Therefore, a post metoclopramide cut-off for the RI < 1.00 offered 100% specificity in excluding an APA on that side. Conclusions: acute DA2 antagonism exerts a prominent secretagogue effect on aldosterone, but due to a proportionally similar effect on the RI of both sides it did not increase the LI. However, it can increase the specificity of the RI for excluding an APA. This finding might be of particular diagnostic value for AVS studies that are not bilaterally selective.

Cure With Cryoablation of Arterial Hypertension Due to a Renin-Producing Tumor

BACKGROUND We herein report on a 20 years old woman with stage I hypertension, who was found to carry a renin-producing tumor (RPT). METHODS Due to her young age, the patient underwent screening measurement of plasma renin and aldosterone, abdominal computed tomography (CT) angiography, and selective renal vein renin assessment to identify secondary hypertension. RESULTS The patient was screened for secondary causes of hypertension and was diagnosed with secondary aldosteronism. Therefore, she underwent an abdominal computed tomography (CT) angiography that was reported as unremarkable. Selective renal vein renin studies showed overproduction of renin in the right kidney and a re-evaluation of her CT allowed detection of an 8-mm mass in her right kidney, suggesting the presence of a RPT. Considering the technical difficulty of renal sparing surgery a CT-guided cryoablation was undertaken, which provided long-term cure of arterial hypertension and normalization of plasma active renin concentration. CONCLUSIONS RPTs usually present with a clinical phenotype featuring stage III and/or malignant hypertension and are held to be exceptionally rare. This case is unique in that it presented with stage I hypertension and a mild clinical phenotype. Moreover, to our knowledge this is the first case of RPTs shown to be safely treated with CT-guided cryoablation and found to be cured at long-term.