Ilias Dalainas

Dual Antiplatelet Regime Versus Acetyl-acetic Acid for Carotid Artery Stenting

Carotid artery stenting has been proposed as an option treatment of carotid artery stenosis. The aim of this single-institution study is to compare the dual-antiplatelet treatment and heparin combined with acetyl-acetic acid, in patients who underwent carotid artery stenting. We compared 2 groups of 50 patents each who underwent carotid artery stenting for primary atherosclerotic disease. Group A received heparin for 24 h combined with 325 mg acetyl-acetic acid and group B received 250 mg ticlopidine twice a day combined with 325 mg acetyl-acetic acid. Outcome measurements included 30-day bleeding and neurological complications and 30-day thrombosis/occlusion rates. The neurological complications were 16% in group A and 2% in group B (p < 0.05). Bleeding complications occurred in 4% in group A and 2% in group B (p > 0.05). The 30-day thrombosis/occlusion rate was 2% in group A and 0% in group B (p > 0.05). Dual antiplatelet treatment is recommended in all patients undergoing carotid artery stenting.

Endovascular Techniques for the Treatment of Ruptured Abdominal Aortic Aneurysms: 7-year Intention-to-treat Results

ObjectivesThe purpose of this single-institution study was to describe our 7-year intention-to-treat results, obtained with the use of endovascular techniques for the treatment of ruptured abdominal aortic aneurysms (rAAA).Patients and MethodsFrom October 1998 until March 2005, a total of 28 patients were admitted or transferred to our department with an rAAA. They were all treated according to a management protocol of intention-to-treat with endovascular techniques. Twenty of the patients received endovascular treatment and the remaining 8 underwent an open surgery procedure.ResultsThe mortality rate of the endovascularly treated patients was 40% (8 in 20), whereas of the 8 surgical patients 3 survived (mortality = 62.5%). The overall mortality rate of the 28 patients admitted with an rAAA was 46.4% (13 of 28 patients).ConclusionsIn our experience the intension-to-treat protocol for rAAA offered acceptable results in terms of mortality rates. Multi-center studies are necessary to establish the role of endovascular treatment in patients with rAAA.

Management of complicated and uncomplicated acute type B dissection. A systematic review and meta-analysis

BACKGROUND The management of acute type B dissection represents a clinical challenge. We undertook a systematic review of the available literature regarding medical, surgical and endovascular treatments of acute type B aortic dissection and combined the eligible studies into a meta-analysis. METHODS An extensive electronic health database search was performed on all articles published from January 2006 up to November 2013 describing the management of acute type B aortic dissection. Studies including less than 15 patients were excluded. RESULTS ACUTE COMPLICATED TYPE B DISSECTION: overall, 2,531 patients were treated with endovascular repair (TEVAR) and the pooled rate for 30-day/in-hospital mortality was 7.3%. The pooled estimates for cerebrovascular events, spinal cord ischemia (SCI) and total neurologic events were 3.9%, 3.1% and 7.3%, respectively. A total of 1,276 patients underwent open surgical repair and the pooled rate for 30-day/in-hospital mortality was 19.0%. The pooled rate for cerebrovascular events was 6.8%, for SCI 3.3% and for total neurologic complications 9.8%. Acute uncomplicated type B dissection: outcome of 2,347 patients who underwent conservative medical management were analyzed. The pooled 30-day/in-hospital mortality rate was 2.4%. The pooled rate for cerebrovascular events was 1%, for SCI 0.8% and for overall neurologic complications 2%. CONCLUSIONS Endovascular repair provides a superior 30-day/in-hospital survival for acute complicated type B aortic dissection compared to surgical aortic reconstruction. However, open repair still has a significant role as endovascular repair is not applicable in all patients and there remains concerns regarding the durability of this technique. TEVAR seems to have a more favorable outcome regarding aortic remodeling and the aortic-specific survival rate when compared with medical therapy alone. Randomized controlled trials focusing on the prognostic factors of early and late complications in uncomplicated type B dissections are needed.

Aortic Neck Dilatation and Endograft Migration are Correlated with Self-Expanding Endografts:

Purpose: To compare self-expanding and balloon-expandable stent-grafts in terms of aortic neck dilatation and endograft migration. Method: Two-hundred and forty-two patients (178 men; mean age 68 years, range 56–91) underwent elective endovascular repair of abdominal aortic aneurysm. Two-hundred self-expanding (115 Excluder, 48 Endologix, 23 Vanguard, 10 Anaconda, and 4 Talent) and 42 balloon-expandable (Lifepath) endografts were used. All patients underwent contrast-enhanced computed tomography (CT) prior to the intervention, at 1, 3, and 6 months after the procedure, and annually thereafter. Comparison was made between the first and the last followup CT scans. Results: Fifty-five (27.5%) of the 200 patients treated with self-expanding endografts had aortic neck dilatation compared to only 3 (7.1%) of the 42 patients treated with balloon-expandable endografts (p=0.023). Forty-nine (24.5%) patients in the self-expanding group versus only 3 (7.1%) patients of the balloon-expandable group presented with endograft migration (p=0.034); all had dilated necks. The difference between the means of neck dilatation for the Lifepath balloon-expandable stent-graft and the Excluder self-expanding endoprosthesis was statistically significant (p=0.011, 95% CI 0.07 to 0.91). Conclusion: Aortic neck dilatation following endovascular AAA repair appears to be correlated with self-expanding endografts, which may contribute to a higher incidence of graft migration compared to that occurring with balloon-expandable endografts.

Aortoenteric Fistulae: Present-Day Management

An aortoenteric fistula (AEF) is a communication between the aorta and an adjacent loop of the bowel. The three most useful diagnostic modalities for detecting AEF are abdominal computed tomography scan with intravenous contrast, esophagogastroduodenoscopy, and arteriography. The treatment of AEFs has improved in recent years, but despite the multiple surgical techniques reported, many of the patients do not survive or are left debilitated after treatment. Endovascular repair is an efficient and safe method to stabilize patients with life-threatening AEFs. The aim of this study is to provide a comprehensive and synthetic review of the latest advantages on the diagnosis and management of primary and secondary AEF.

Late Gastrointestinal Bleeding After Infrarenal Aortic Grafting: A 16-Year Experience

PurposeTo review the manifestation and management of gastrointestinal (GI) bleeding caused by secondary aortoenteric fistula (AEF) after infrarenal aortic grafting.MethodsBetween 1991 and 2006, nine patients underwent emergency treatment for secondary AEF localized in the duodenum (78%), ileum (11%), or sigmoid colon (11%). Three (33%) patients suffered hypovolemic shock. There were two (22%) real fistulas and seven (78%) paraprosthetic fistulas. Graft infection was confirmed in four (45%) patients and four (45%) had proximal sterile pseudoaneurysms. Surgical management consisted of graft removal with (n = 5) or without simultaneous extra-anatomic bypass (n = 1), in situ Dacron graft interposition (n = 3), ileo-duodenorrhaphy (n = 8), sigmoidectomy with colostomy (n = 1), and segmentary ileectomy (n = 1). Endografting was used only as a temporary measure to control bleeding in two patients.ResultsThe mortality rate was 55% (n = 5). There were no intraoperative deaths, but 75% of the septic patients, 66% of those with preoperative hemodynamic instability, 50% of those with pseudoaneurysms, and 100% of those who required bowel resection died during the early postoperative period. Moreover, all of the surviving patients suffered early postoperative morbidity, resulting in prolonged intensive care unit stay and hospitalization.ConclusionsSecondary AEF is life-threatening, difficult to treat, and associated with high morbidity and mortality, especially in patients with sepsis or hemodynamic instability and those requiring bowel resection.

Endovascular Treatment of the Carotid Stump Syndrome

In patients with an occluded internal carotid artery, the carotid stump syndrome is a potential source of microemboli that pass through the ipsilateral external carotid artery and the ophthalmic artery to the territory of the middle cerebral artery. Thus, the syndrome is associated with carotid territory symptoms although the internal carotid artery is occluded. Surgical exclusion of the internal carotid artery associated with endarterectomy of the external carotid artery has been described as the gold standard of treatment by many authors. This report is the second case, to our knowledge, of endovascular treatment of the carotid stump syndrome with the use of a stent-graft.

Endograft Accommodation on the Aortic Bifurcation: An Overview of Anatomical Fixation and Implications for Long-term Stent-Graft Stability

In light of the results of randomized trials, it seems that despite the favorable short and midterm outcomes of standard endografts, concern over endograft migration has escalated, as this event will be responsible for almost all late complications in endovascular aneurysm repair (EVAR). Migration forces, both caudal and sideways, depend heavily on blood pressure, inlet diameter, and angulation of the stent-graft, while the bifurcation generates more force than any other segment of the stent-graft. It thus seems that the position of the endografts flow divider influences force distribution and migration risk. Additionally, due to concomitant ongoing aortic degeneration, postoperative dilatation of the infrarenal aortic neck poses a threat to EVAR patients as soon as the diameter of the infrarenal neck reaches the dimensions of the proximal graft. This review evaluates the significance of endograft accommodation on the aortic bifurcation and cumulative experience of the only endografts utilizing this feature: the Zenith Composite and the Powerlink.

Retrograde Transpopliteal Approach of Iliofemoral Lesions

Purpose: Aim of this study is to present our initial experience with the use of the retrograde popliteal artery access in patients with certain anatomic lesions. Methods: Between September 2008 and September 2010, 24 patients underwent a transpopliteal retrograde subintimal recanalization. Instead of its usage when antegrade recanalization failed, the “facedown” technique was preferred as a first choice in patients with common femoral artery stenosis or occlusion, proximal lesions of the superficial femoral artery (SFA) with no stump, severe obesity, tandem iliac, and SFA lesions. Results: Technical success was achieved in 91.7% of patients.The complication rate was 12.5%. The primary patency at 6, 12, and 18 months was 86.4%, 65.8%, and 65.8%, respectively. Conclusions: The retrograde popliteal artery approach can be considered as the primary SFA recanalization strategy in carefully selected patients, with competitive immediate and midterm results.

A Word of Caution Before Killing Hypogastric Arteries

The clinical investigation performed by Bratby et al. [1] regarding internal iliac artery (IIA) embolization prior to endovascular aneurysm repair (EVAR) is very important because it highlights the relatively safe feasibility of EVAR in such borderline iliac anatomies. In a similar study we conducted [2] including 33 unilateral and 8 bilateral IIA embolizations, we found similar results, with five cases of buttock/hip claudication (12.2%) and no case of bowel or spinal cord ischemia. While buttock claudication is the most frequent complication [1, 2], bowel and spinal cord ischemia are the major complications of IIA embolization. Bowel ischemia has been considered a multifactorial problem in open surgery, considering embolism, long-term hypoperfusion, mesentery stretch, traction or compression due to self-retraining retractor, bowel reperfusion syndrome, and collateral circulation. While most of these situations are not present during EVAR, collateral arterial circulation is a common risk factor. Yano et al. [3] reported high rates of bowel ischemia with hypogastric exclusion after EVAR, attributed to stenosis or occlusion of the ipsilateral femoral artery. Collateral arterial vasculature seems to play an important role in bowel ischemia after EVAR [4]. Even if there is no angiographic evidence that could forecast bowel ischemia, before proceeding to bilateral IIA exclusion, patients’ collateral arterial circulation should be studied, aiming for the preoperative identification of celiac artery or superior mesenteric artery stenosis or obstruction and patency of external iliac artery and common femoral artery collaterals. Furthermore, operators should be particular accurate regarding the preservation of these circumflex collaterals during surgical preparation of the femoral arteries. Regarding spinal cord ischemia prevention when planning IIA exclusion, particular attention should be paid to the patient’s medical history. Thoracic aortic procedures, endovascular or surgical with sacrifice of intercostal arteries, and subclavian artery stenosis or occlusion are important factors that could increase the risk of spinal cord injury. In conclusion, I believe that when bilateral IIA exclusion is considered as an operative strategy prior to EVAR, preoperative imaging workup should focus also on the status of the patient’s collateral circulation.