Konstantinos O. Papazoglou

Endovascular Treatment of Popliteal Artery Aneurysms

OBJECTIVE To present the results of the endovascular treatment of popliteal artery aneurysms. METHODS From April 1999 to January 2002, 11 patients, aged 40-94 years, with 12 popliteal aneurysms were treated. Nine (75%) underwent an endoluminal repair, of whom three were done emergently due to an aneurysm rupture. Aneurysm diameter was 28-105 (mean 69) mm. A Hemobahn stent graft was inserted in six, Wallgraft in two and Passager in one case. RESULTS During a mean follow-up of 14 (3-31) months, four (44%) thromboses occurred: two in the early postoperative period (30 days) and two during the late postoperative period. Two of the four occluded grafts were successfully reopened, and in the one a stenosis of the distal end of the stent graft was treated with balloon dilatation. Patency rates at 1 and 12 months were 64/47% (primary patency) and 88/75% (secondary patency), respectively. CONCLUSION Initial experience with endovascular treatment of the popliteal aneurysm in high-risk patients yielded modest results. Larger number of patients and further follow-up time is necessary to evaluate the long-term results.

Impact of Endograft Material on the Inflammatory Response After Elective Endovascular Abdominal Aortic Aneurysm Repair

The purpose of this paper is to examine the impact of endograft material on the inflammatory response after elective endovascular abdominal aortic aneurysm repair. Consecutive patients (n=22, all men, 53 to 82 years old) were divided into 2 groups according to the graft material used: In group A (n=12) the endovascular device was made of polyester and in group B (n=10) the device was made of expanded polytetrafluoroethylene (ePTFE). All patients received antiinflammatory drugs in the perioperative period. Fever, white blood cells and platelet count, serum concentrations of cytokines (interleukin 6 [IL-6], tumor necrosis factor alpha [TNF-a], interleukin 8 [IL-8], acute-phase proteins high-sensitivity C-reactive protein [hsCRP] and alpha1-antitrypsin [a1-antitrypsin]), and complement protein (C3a) were measured preoperatively and 1, 3, 6, 24, 48, and 72 hours after aneurysm exclusion. One patient in each group had a systemic inflammatory response syndrome with 2 of the systemic inflammatory response syndrome (SIRS) criteria. No other complication associated with inflammation were present in any patient. Fever was more frequent in group A patients. Increases of white blood cells and serum concentrations of IL-6, TNF-a, hsCRP, a1-antitrypsin, and C3a and decrease of platelet count were recorded in both groups, but no statistically significant difference between them was recorded. However, serum concentrations of IL-8 were significantly higher in group A patients 24 hours postoperatively (p=0.01). No significant difference was apparent in the biological response between patients receiving a polyester or an ePTFE stent graft, except for fever and serum concentrations of IL-8.

Outcomes of endovascular aneurysm repair with selective internal iliac artery coverage without coil embolization

OBJECTIVE Endovascular aneurysm repair (EVAR) of abdominal aortic aneurysms (AAAs) that also involve the common iliac artery (CIA) typically is accomplished by endograft limb extension into the external iliac artery (EIA). In order to prevent endoleak, the internal iliac artery (IIA) is usually embolized, or alternatively a branched limb is deployed. However, IIA embolization is associated with longer operative time and increased use of contrast and radiation. It has been our practice not to routinely coil embolize the IIA. The purpose of this study was to present the midterm outcomes of this approach. METHODS Between April 1997 and June 2010, 137 patients (130 men; mean age, 70.9 years; range, 45-92 years) underwent EVAR of their AAA and had IIA coverage without coil embolization in 112 patients (no embolization [NE] group) and after coil embolization in 25 patients (coil embolization [CE] group). Anatomic indications for coverage of the IIA without coil embolization included presence of adequate sealing in the distal 5 mm of the CIA, or sealing ring at the origin of the CIA, or IIA diameter <5 mm. Preoperative mean AAA size was 60 ± 14 mm, and mean CIA diameter was 38 ± 13 mm. Postoperative computed tomography (CT) scanning was performed at 1, 6, and 12 months, and yearly thereafter. RESULTS Thirty-day mortality was 0.7% (1 of 137 patients). A patient presented with gluteal skin necrosis (0.7%). The incidence of postoperative buttock claudication was not different between the two groups (NE: 15 of 112 patients; CE: 3 of 25 patients; P = .852). Procedure and fluoroscopy time, contrast use, and hospital stay were significantly reduced in the NE group. Patients were followed up for 33 ± 30 months. During follow-up, 44 patients died (32.1%) and in 3 of them (2.2%), death was AAA-related. There was no difference in cumulative survival between the two groups at 1, 2, 3, and 4 years, respectively. Secondary interventions were performed in 20 of 137 patients (14.5%), including three conversions for proximal endoleak. There was no difference between the two groups in the incidence of secondary interventions (NE: 18 of 112 patients; CE: two of 25 patients; P = .301) and freedom from reintervention at 1, 2, 3, and 4 years, respectively. Ten patients (8.9%) from the NE group presented a type II endoleak during follow-up. Seven of them were associated with the covered IIA; none required reintervention. CONCLUSIONS Stent graft coverage of the IIA without coil embolization is a safe, simple, and effective maneuver for the treatment of aortoiliac aneurysms, with a low incidence of postoperative complications and reinterventions and acceptable immediate and midterm results.

Usefulness of the Hardman index in predicting outcome after endovascular repair of ruptured abdominal aortic aneurysms

OBJECTIVES The Hardman index, which has five variables, has been recommended as a predictor of outcome after open repair of ruptured abdominal aortic aneurysms (RAAAs). It has been reported that the presence of three or more variables is uniformly fatal. The aim of this study was to test the same model in an independent series of RAAA patients undergoing endovascular repair. METHODS A consecutive series of 41 patients undergoing endovascular repair for RAAA during an 8-year period was analyzed retrospectively. Thirty-day mortality and patient variables, including the five Hardman risk factors of age >76 years, serum creatinine >190 micromol/L, hemoglobin <9 g/dL, loss of consciousness, and electrocardiographic (ECG) evidence of ischemia, were recorded. The Hardman index and a revised version of the index with four variables (without ECG ischemia) were calculated and related to clinical outcome. RESULTS Operative mortality was 41% (17 of 41). On univariate analysis, only age >76 years (P = .01) and the use of local anesthesia (P < .0001) were statistically significant. Loss of consciousness (P = .05) showed a trend toward a higher mortality, albeit not statistically significant. On multivariate analysis, the use of local anesthesia was the only significant predictor of survival (odds ratio [OR], 0.03; 95% confidence interval [CI], 0.003-0.25, P = .001). Again, loss of consciousness showed an association with a higher chance of dying but did not achieve statistical significance (OR, 6.30; 95% CI, 0.93-42.51, P = .059). The original and revised versions of the Hardman index were both significantly associated with death (P = .02 and P = .001, chi(2) test for trend). The cumulative effect of 0, 1, 2, and >/=3 risk factors on mortality was 0%, 27%, 36%, and 71% for the original index, and 12.5%, 21%, 60%, and 78% for the revised version, respectively. Four and two patients with a score of >/=3 in each version of the index survived endovascular repair. CONCLUSIONS The Hardman index, with or without incorporating ECG ischemia, seems to be a simple and useful predictive tool in patients undergoing endovascular repair of RAAA, with the mortality rate increasing along with the Hardman score. However, the index cannot be used to accurately identify patients with no chance of survival after endovascular repair.

Cerebral Hyperperfusion After Carotid Stenting: A Transcranial Doppler and SPECT Study

Aim: To document the incidence of symptomatic cerebral hyperperfusion after carotid stenting and to determine possible predisposing factors. Methods: A prospective study of 29 consecutive patients undergoing carotid stenting. All patients underwent 1) brain computed tomography scan and magnetic resonance imaging, 2) transcranial Doppler including assessment of cerebrovascular reactivity of the ipsilateral middle cerebral artery and 3) 99m hexamethyl-propyleneamine oxime brain single photon emission computed tomography, before and after the procedure. Results: A total of 5 patients developed adverse neurological events, 4 of them transient. Cerebral hyperperfusion was documented in two of these (6.9%). Both had exhausted cerebrovascular reactivity in the preoperative transcranial Doppler examination. No consistent pattern of interhemispheric asymmetry in brain perfusion was found in these patients. Conclusions: Symptomatic cerebral hyperperfusion is not uncommon after carotid stenting. There seems to be a link between exhausted cerebrovascular reactivity of the ipsilateral middle cerebral artery and increased risk of cerebral hyperperfusion.

Axillary artery transection after recurrent anterior shoulder dislocation.

Axillary artery transection after recurrent anterior shoulder dislocation is extremely rare. We present 2 such patients. The first, a 62-year-old man, presented with acute ischemia and a large hematoma in the axilla and chest wall. The second, a 63-year-old man, had a pseudoaneurysm and palpable peripheral pulses. Both underwent urgent computed tomography, which confirmed the clinical diagnosis, and the patients were taken to the operating room. In the first patient, intraoperative angiogram through both the brachial and the femoral route showed complete disruption of the axillary artery rendering an endovascular approach not possible. Proximal balloon occlusion was then undertaken through the femoral artery, controlling the bleeding and allowing easier dissection of the ruptured segment. Revascularization was performed with an interposition polytetrafluoroethylene (PTFE) bypass restoring normal blood supply to the upper extremity. The second patient had a Viabhan (W.L. Gore, Flagstaff, Ariz) stent-graft implanted through the brachial artery with an excellent clinical and angiographic result. As expected, both patients had significant neurologic morbidity due to associated brachial plexus palsy. Ruptured axillary artery after shoulder dislocation is very uncommon. Endovascular repair and hybrid procedures combining open and endovascular techniques can offer reliable solutions to these challenging problems.

Endovascular Management of Lap Belt–Related Abdominal Aortic Injury in a 9-Year-Old Child

Blunt abdominal aortic trauma is a rare occurrence in children with only a few patients having been reported in the literature. Most such cases have been described in the context of lap belt injuries. We report a 9-year-old boy who suffered lap belt trauma to the abdomen during a high-speed road traffic accident resulting to the well-recognized pattern of blunt abdominal injury, that is, the triad of intestinal perforation, fractures of the lumbar spine, and abdominal aortic injury. The latter presented with lower limb ischemia due to dissection of the infrarenal aorta and right common iliac artery. Revascularization was achieved by endovascular means using 2 self-expanding stents in the infrarenal aorta and the right common iliac artery. This case is one of the few reports of lap belt-related acute traumatic abdominal aortic dissection in a young child and highlights the feasibility of endovascular management in the pediatric population.

Spontaneous rupture of the visceral abdominal aorta: endovascular management using the periscope graft technique.

Purpose To describe the endovascular management of a spontaneous rupture of the visceral abdominal aorta. Case Report A 69-year-old man presented as an emergency with a ruptured non-aneurysmal visceral abdominal aorta that extended from just below the celiac trunk to the right renal artery; the superior mesenteric artery (SMA) appeared to be occluded. The rupture was presumed to be due to a penetrating atherosclerotic ulcer. An endovascular approach was devised in which an Excluder aortic cuff would be deployed immediately below the origin of the celiac artery, covering the ruptured aortic segment and the occluded SMA. However, a second cuff was required distally to seal the rupture. To maintain perfusion to the right renal artery, a Viabahn stent-graft was deployed into the renal artery using the periscope technique. A stent was also required in the celiac trunk, which had been inadvertently covered. The patient had an uneventful recovery; follow-up imaging at 1 year revealed no endoleak and resolution of the hematoma. Conclusion Spontaneous rupture of a non-aneurysmal visceral abdominal aorta is extremely challenging and potentially fatal. Endovascular management using the periscope stent-graft technique to facilitate aortic stent-grafting may offer an attractive bailout option with satisfactory early results.

Open Versus Endovascular Repair of Inflammatory Abdominal Aortic Aneurysms A Comparative Study and Meta-Analysis of the Literature

Objectives: Open surgical repair (OSR) of inflammatory abdominal aortic aneurysms (IAAAs) can have significant morbidity. The aim of the present investigation was to compare IAAA outcome after OSR and endovascular aneurysm repair (EVAR) and perform a meta-analysis of the literature. Methods: Twenty-seven patients with an intact IAAA operated on during a 21-year period were included. Results: Nine patients were managed with EVAR and 18 with OSR. In the EVAR group, the number of transfused red blood cell units (P = .001), procedure duration (P < .001), and postoperative hospitalization (P = .004) were significantly reduced compared to OSR. A trend for decreased morbidity with EVAR (11% vs 33% for OSR, P = .36) was observed. On literature review and meta-analysis, morbidity after EVAR was 8.3%, significantly lower compared to OSR (27.4%, P = .047). Mortality for nonruptured IAAAs was 0% after EVAR and 3.6% after OSR (P = 1.00). Conclusions: Endovascular aneurysm repair of IAAAs is associated with decreased procedure duration, transfusion needs, hospitalization, and morbidity compared to OSR.

Ruptured Mycotic Common Femoral Artery Pseudoaneurysm: Fatal Pulmonary Embolism after Emergency Stent-Grafting in a Drug Abuser

The rupture of a mycotic femoral artery pseudoaneurysm in an intravenous drug abuser is a limb- and life-threatening condition that necessitates emergency intervention. Emergency stent-grafting appears to be a viable, minimally invasive alternative, or a bridge, to subsequent open surgery. Caution is required in cases of suspected concomitant deep vein thrombosis in order to minimize the possibility of massive pulmonary embolism during stent-grafting, perhaps by omitting stent-graft postdilation or by inserting an inferior vena cava filter first. We describe the emergency endovascular management, in a 60-year-old male intravenous drug abuser, of a ruptured mycotic femoral artery pseudoaneurysm, which was complicated by a fatal pulmonary embolism.