Konstantinos Spanos

Systematic review and meta-analysis of migration after endovascular abdominal aortic aneurysm repair

Aim To identify patients who are under higher threat for migration because of an old generation stent graft application. Methods A systematic review and meta-analysis of the literature was undertaken to identify all studies which included older generation endografts and data reporting on graft migration after EVAR. Outcome data were pooled and combined, and were calculated using fixed or random effects models. Results From 2000 to 2014, 22 retrospective studies were identified reporting on stent- graft migration after EVAR (8.6%). From those patients, 39% received re-intervention with the mean time of identification ranging from 12 to 36 months. Six of these retrospective nonrandomized studies were eligible for meta-analysis. AAA diameter (AAA diameter: 0.719 mm; 95% confidence interval [CI]: 0.00065–1.4384 mm; p = 0.00497) and neck length (neck length: 4.36 mm; 95% CI: 1.3277–7.394; p = 0.0048) were the only significant factors associated with stent- graft migration. Neck diameter and neck angulation did not have any important influence on stent-graft migration. Conclusions Patients with large AAA and short necks who were treated with older generation stent grafts such as AneurX and Talent are in higher risk for endograft migration than others. Stent- graft migration consists of an insidious and underestimated threat.

Is the Reevaluation of Cardiac Status and Medical Treatment Mandatory for Patients With Coronary Artery Disease After Endovascular Aneurysm Repair

Over the past 2 decades, endovascular aneurysm repair (EVAR) has become established as the treatment of choice for abdominal aortic aneurysm (AAA) in many vascular centers instead of the traditional open repair. However, in recent studies, there was no difference in the long-term survival between the 2 treatments. The important commonality for both treatments is the cardiovascular morbidity and mortality. This is reasonable because AAAs positively correlate with the presence of coronary artery disease (CAD). A prevalence of AAAs as high as 18.2% has been reported in patients undergoing coronary artery bypass grafting. In addition to that, the prevalence of CAD in patients suffering from AAAs reaches to 53%. EVAR and open repair are indeed effective treatment options for AAA, but related changes in cardiac status and arterial stiffness are not well established. The proximal aorta is a highly compliant vessel, which reduces left ventricle (LV) workload and dampens the propagated pressure wave. After EVAR or open AAA repair, the interposition of prosthetic stent-grafts and grafts, respectively, may acutely reduce the compliance. As a result, the input impedance is significantly increased and systemic arterial compliance is significantly decreased, with a subsequent increase in systolic and pulse pressures leading to left ventricular hypertrophy. Thus, EVAR or open repair may have an adverse effect on cardiovascular hemodynamics, which in turn may lead to hypertension, cardiac hypertrophy and ischemia, the development of vessel wall disease, and thrombosis formation. In the past, studies have investigated the hemodynamics of thoracic aortic aneurysms (TAAs) and AAAs after endovascular or open repair, and the research in this field is still ongoing. However, most of the studies have been related to AAAs because of their higher incidence. Such studies have been based on 3-dimensional (3D) simulations with good reproduction of the pressure and flow waveforms of the aorta during the cardiac cycle. Nowadays, temporal variation and spatial patterns of wall shear stress are presented in the aortic arch and thoracic aorta together using rigid wall and 3D fluidstructure interaction (FSI) models or even dynamic magnetic resonance angiography (MRA) and wall motion tracking software. However, the clinical significance for patient outcome and follow-up as regards the cardiac and blood pressure level changes after the procedure have not been adequately assessed for patients with CAD suffering from AAA. It is clear that vascular stiffness, LV hypertrophy, and diastolic dysfunction are increased after EVAR. First, elevated aortic vascular stiffness is indicated by the postEVAR elevation in the ankle-brachial pulse wave velocity (baPWV). The LV mass index (LVMI) increases significantly after EVAR, and these changes are positively correlated with those in baPWV. Studies have shown that arterial stiffness is associated with LV hypertrophy, which has been linked to increased risk of atherosclerotic heart disease, myocardial infarction, and stroke. PWV is also increased due to graft interposition in open repair, and it does not significantly differ from PWV changes after EVAR, although there is a study that suggests that stent-grafts increase reflected waves more than graft prostheses. Additionally, there is a difference between 573248 JETXXX10.1177/1526602815573248Journal of Endovascular TherapySpanos and Giannoukas research-article2015

Early Outcomes of the t-Branch Off-the-Shelf Multibranched Stent-Graft in Urgent Thoracoabdominal Aortic Aneurysm Repair

Purpose: To assess the short-term outcomes of the multibranched off-the-shelf t-Branch stent-graft for urgent thoracoabdominal aortic aneurysm (TAAA) repair and to evaluate the impact on outcomes of the learning curve and adherence to the instruction for use (IFU). Methods: Between 2014 and 2017, 42 patients (mean age 73.3±7 years; 26 men) underwent urgent TAAA treatment using the t-Branch stent-graft [18 in the early (2014–2015) period and 24 in the late (2016–2017) period]. Nearly half the patients were symptomatic (n=18) and 12 had contained rupture. Aneurysm diameter >80 mm was present in 12 (mean diameter 77.7±13.2 mm). Nineteen patients did not meet the IFU for the t-Branch due to target vessel anatomy. The primary endpoints were spinal cord ischemia (SCI), renal function impairment, and 30-day mortality. Target vessel patency and endoleak incidence were assessed at 30 days. Multivariate analyses examined associations between perioperative variables and outcomes; the results are presented as the odds ratio (OR) and 95% confidence interval (CI). Results: The technical success rate was 93% (39/42). Successful catheterization was achieved in 150/155 target vessels (97%). The postoperative SCI rate was 21% (5 paraplegia/4 transient paraparesis) and was correlated with age (OR 1.26, 95% CI 1.01 to 1.56, p=0.04). The renal function impairment rate was 23% (10/42; 2 temporary, 2 permanent dialysis) and was correlated with early experience (OR 7.74, 95% CI 1.3 to 43.9, p=0.019). The 30-day mortality was 14% (no intraoperative deaths); no factor was associated with mortality. During the first month, the incidences of type I, II, and III endoleaks were 0%, 43%, and 0%, respectively; branch patency was 99% (150/151). Procedure time decreased in the later experience (479±333 vs 407±25 minutes, p=0.09), though it was increased in cases outside the IFU (497±135 vs 389±118 minutes, p=0.009), along with fluoroscopy time (121±48 vs 92±33 minutes, p=0.036). Conclusion: Endovascular repair of urgent TAAA using the t-Branch is a feasible treatment option with acceptable 30-day mortality and morbidity in terms of SCI and renal function impairment. Adherence to the IFU prolonged procedure time but had no effect on outcomes. Increased experience of such cases over time may improve outcomes.

Patterns in the management of superficial vein thrombosis.

Objective To highlight current practice patterns in management of superficial vein thrombosis. Methods An electronic survey was conducted using the mailing lists of the Mediterranean League of Angiology and Vascular Surgery and European Venous Forum regarding superficial vein thrombosis diagnosis, investigation, and treatment. Results The response rate was 41% (175/430) and the majority of the participants were vascular surgeons practicing in a hospital. More experienced physicians considered superficial vein thrombosis as a medical issue of moderate seriousness and performed duplex ultrasound for confirmation of diagnosis. Elastic stockings were recommended by 87% of the physicians, while 57% prescribed nonsteroidal anti-inflammatory drugs. Eighty six percent advised anticoagulation, although a large disparity was shown regarding regime, dose, and duration. Thrombophilia test was regularly suggested by 19% of the physicians. Ligation of the saphenofemoral junction was the treatment of choice by those who suggested intervention in the acute phase of superficial vein thrombosis. Conclusions A great disparity exists in the management of superficial vein thrombosis. Current guidelines have not been adopted by physicians; more focused training is needed for those involved in the management of venous diseases.

Endovascular treatment of traumatic internal carotid artery pseudoaneurysm.

INTRODUCTION Traumatic internal carotid artery pseudoaneurysm (TICAP) is the most common cause of stroke in young adults. The treatment of TICAP with open surgery poses excess risk, thus during last decade endovascular treatment strategies have been applied. AIM To assess the efficacy and the existing experience of endovascular treatment of TICAP. METHODOLOGY A systematic review of the literature was undertaken to identify all reported cases of endovascular treatment of TICAP from 1998 to 2015 in MEDLINE, EMBASE and Cochrane Central Register of Controlled Trials. RESULTS A total of 193 patients (139 males, 75%) with mean age of 30.8±2.2 years in 23 case studies, were treated for their TICAP with endovascular treatment. The main causes of TICAP were road traffic accidents 51%, assaults 12%, fall from height 8% and other miscellaneous causes were 29%. In 8/23 studies, the patients were operated emergently, in 9/23 at least 1 month after the carotid injury, and in 6/23 the time between the injury and the operation was not reported. The total success rate of pseudoaneurysm occlusion was 84% (162/193). The reported peri-procedural morbidity rate was 6% (11/185; 3 TIA, 7 strokes and 1 subclavian artery dissection), and the peri-operative mortality rate was 1.2% (2/162). Most patients received post-operatively antiplatelet therapy (either single or dual) and the duration of the administration ranged from 3 months to long term. During their follow up (ranging from 4 days to 13 years) only 6 patients required re-intervention, and this was undertaken with endovascular approach. CONCLUSION Endovascular therapy tends to be an effective option for the treatment of TICAP with low morbidity and mortality rates.

Carotid Bifurcation Geometry and Atherosclerosis

Hemodynamic changes occurring at the initial segments of the arterial bifurcations appear to play an important role in the development of atherosclerotic plaque. Therefore, arterial geometry might be a potential marker for atherosclerosis. Considerable evidence suggests that geometry can influence local hemodynamics at the carotid bifurcation contributing to the development of atheroma. Bifurcation angle, differences in the area ratios including the flare, proximal curvature, sinus bulb width, and tortuosity of the internal or external carotid artery have been listed as potential contributory elements. These morphometric details have been studied not only in postmortem examination but also with the help of imaging modalities such as ultrasound, digital subtraction angiography, computed tomography angiography, and the assistance of computational models and magnetic resonance angiography. The establishment of certain anatomical and geometrical details in addition to traditional risk factors may help in the identification of patients at high risk of developing carotid artery disease. We reviewed the literature to highlight the evidence on the importance of various geometrical details in the development of carotid atheroma and to suggest areas of future research.

Factors Associated With Ulcer Healing and Quality of Life in Patients With Diabetic Foot Ulcer

A prospective nonrandomized cohort study on consecutive diabetic patients with foot ulcer was undertaken to assess the factors associated with the healing process or limb salvage and evaluate the impact of their treatment on their quality of life. Quality of life was evaluated using Diabetic Foot Ulcer Scale–Short Form (DFS-SF) questionnaire before and after treatment. A total of 103 diabetic patients with ulcer (mean age 69.7 ± 9.6 years, 77% male) were treated and followed up for 12 months. Ulcer healing, minor amputation, and major amputation rates were 41%, 41%, and 18%, respectively, while the mortality rate was 18%. Ulcer healing was associated with University of Texas wound grade 1 and the Study of Infections in Diabetic feet comparing Efficacy, Safety and Tolerability of Ertapenem versus Piperacillin/Tazobactam trial’s diabetic foot infection wound score. Limb loss was associated with nonpalpable popliteal artery, longer in-hospital stay, and delay until referral. Quality of life was improved in all domains of DFS-SF (P < .0001) throughout the cohort of our patients regardless of their outcome, and no outcome (healing, minor amputation, or major amputation) was superior to other. Significant improvement was observed in all domains of hygiene self-management after consultation during the follow-up period.

The association of simple renal cysts with abdominal aortic aneurysms and their impact on renal function after endovascular aneurysm repair

We validated the association of simple renal cysts with abdominal aortic aneurysm and other cardiovascular factors and assessed simple renal cysts’ impact on renal function before and after endovascular abdominal aortic aneurysm repair. A retrospective analysis of prospectively collected data was conducted. Computed tomography angiograms of 100 consecutive male patients with abdominal aortic aneurysm who underwent endovascular abdominal aortic aneurysm repair (Group 1) were reviewed and compared with 100 computed tomography angiogram of aged-matched male patients without abdominal aortic aneurysm (Group 2). Patients’ demographic data, risk factors, abdominal aortic aneurysm diameter, the presence of simple renal cyst and laboratory tests were recorded. No difference was observed between the two groups in respect to other cardiovascular risk factors except hyperlipidemia with higher prevalence in Group 1 (p < 0.05). Presence of simple renal cysts was independently associated with age (p < 0.05) and abdominal aortic aneurysm (p = 0.0157). There was no correlation between simple renal cysts and abdominal aortic aneurysm size or pre-operative creatinine and urea levels. No difference was observed in post-operative creatinine and urea levels either immediately after endovascular abdominal aortic aneurysm repair or in 12-month follow-up. In male patients, the presence of simple renal cysts is associated with abdominal aortic aneurysm and is increasing with age. However, their presence is neither associated with impaired renal function pre-endovascular abdominal aortic aneurysm repair and post-endovascular abdominal aortic aneurysm repair nor after 12-month follow-up.

Renal function impairment in patients undergoing elective EVAR vs. elective open repair during follow up period: a systematic review of the literature.

BACKGROUND Endovascular (EVAR) or open surgical (OSR) repair are current treatment options for abdominal aortic aneurysm (AAA). OBJECTIVE To produce a systematic review comparing the impact of these 2 treatment options on renal function during mid- and long term follow up. METHODS The MEDLINE, EMBASE and Cochrane databases and key references were searched. RESULTS Six studies were included from 2000 to 2016, (4 retrospective and 2 RCT studies) reporting on 2,102 patients (54%; 1096 EVAR, 46%; 1006 OSR). The mean age in EVAR group ranged from 69.4 to 73.8 years (91% males), and in OSR group from 68 to 73.6 years (91% males). The data were too heterogeneous to perform a meta-analysis. All studies used GFR (Glomerular Filtration Rate) or estimated GFR (eGFR) to record renal function. The commonest risk factors were the presence of hypertension (77.5%), hyperlipidaemia (48.3%), coronary artery disease (42%) and smoking (37.8%). During follow up, new events of renal impairment (increase >20% in GFR) in EVAR patients and in OSR patients were 58 (5.3%) and 52 (5.2%), respectively. The mean GFR was decreased during follow up period in both types of the procedure. CONCLUSION There is lack of definitive evidence to prove the superiority of OSR over EVAR regarding renal function in the post-operative follow up period. It appears that renal impairment may occur after both interventions. Further prospective research is needed to clarify the issue.

Complexity of persistent type II endoleak associated with sac expansion after endovascular abdominal aortic aneurysm repair

Type II endoleak after endovascular aortic aneurysm repair still remains the Achilles’ heel of the treatment, the source of which regularly is difficult to identify and treat. We present a patient with a persistent type II endoleak associated with a continuous aneurysm sac expansion after endovascular aortic aneurysm repair for which many diagnostic modalities were used during his follow-up such as duplex scan, computed tomography angiography and magnetic resonance angiography. Attempts were undertaken to treat the source of endoleak including coil micro-embolisation of lumbar arteries and subsequent open ligation of the inferior mesenteric artery, but they failed to eliminate the endoleak. Finally, a middle sacral artery was identified as the source of the endoleak. At that time, the patient was subjected to surgery for sigmoid carcinoma, and simultaneously, a ligation of the sacral artery was undertaken which eventually eliminated the endoleak completely. This case highlights that type II endoleak may be evoked by various sources and there can be a great difficulty to identify these feeding vessels; thus, careful planning for its management is mandatory.