Luciano Bresadola

Intraoperative aorta balloon occlusion: fertility preservation in patients with placenta previa accreta/increta

Objective: To evaluate whether aorta balloon occlusion decreases the rate of hysterectomies and maternal morbidity during extirpative surgery of placenta previa accreta or increta. Methods: We prospectively assessed 33 consecutive patients with placenta praevia and MRI diagnosis of multifocal accreta or increta. Manual removal of the placenta was performed during a scheduled caesarean delivery. In 15 patients, surgery was preceded by balloon catheterization of the abdominal aorta (Intra Abdominal Balloon Occlusion: IABO); 18 patients refusing IABO were considered as controls. We used Fisher’s exact test for categorical variables and Mann–Whitney test for continuous variables. Results: In the IABO group we observed significant decreases in incidence of hysterectomy, estimated blood loss, number of transfused units of red blood cells, postoperative stay and admission to Intensive Care Unit. No IABO-related complications were reported. Conclusions: During scheduled caesarean section for placenta previa multifocally accreta or increta, IABO can prevent hysterectomy in many cases and improves perioperative outcome as it gives the operator time to achieve the haemostasis via curettage and oversewing of the implantation site with acceptable blood loss.

Aortic neck evolution after endovascular repair with TriVascular Ovation stent graft

OBJECTIVE Aortic neck dilation has been reported after endovascular aneurysm repair (EVAR) with self-expanding devices. With a core laboratory analysis of morphologic changes, this study evaluated midterm results of aortic neck evolution after EVAR by endograft with no chronic outward force. METHODS This was a multicenter registry of all patients undergoing EVAR with the Ovation endograft (TriVascular, Santa Rosa, Calif). Inclusion criteria were at least 24 months of follow-up. Standard computed tomography (CT) scans were reviewed centrally using a dedicated software with multiplanar and volume reconstructions. Proximal aortic neck was segmented into zone A (suprarenal aorta/fixation area), zone B (infrarenal aorta, from lowest renal artery to the first polymer-filled ring), and zone C (infrarenal aorta, at level of the first polymer-filled ring/sealing zone). Images were analyzed for neck enlargement (≥2 mm), graft migration (≥3 mm), endoleak, barb detachment, neck bulging, and patency of the celiac trunk and superior mesenteric and renal arteries. RESULTS Inclusion criteria were met in 161 patients (mean age, 75.2 years; 92% male). During a mean follow-up period of 32 months (range, 24-50), 17 patients died (no abdominal aortic aneurysm-related death). Primary clinical success at 2 years was 95.1% (defined as absence of aneurysm-related death, type I or type III endoleak, graft infection or thrombosis, aneurysm expansion >5 mm, aneurysm rupture, or conversion to open repair). Assisted primary clinical success was 100%. CT scan images at a minimum follow-up of 2 years were available in 89 cases. Patency of visceral arteries at the level of suprarenal fixation (zone A) was 100%. Neither graft migration nor barb detachment or neck bulging was observed. None of the patients had significant neck enlargement. The mean change in the diameter was 0.18 ± 0.22 mm at zone A, -0.32 ± 0.87 mm at zone B, and -0.06 ± 0.97 mm at zone C. Changes at zone B correlated significantly with changes at zone C (correlation coefficient, 0.183; P = .05), whereas no correlation was found with zone A (correlation coefficient, 0.000; P = 1.0). CONCLUSIONS No aortic neck dilation occurred in this series at CT scan after a minimum 24-month follow-up. This may suggest that aortic neck evolution is not associated with EVAR at midterm follow-up when an endograft with no chronic outward radial force is implanted.

Outcomes in the emergency endovascular repair of blunt thoracic aortic injuries.

Thoracic aorta blunt injury (BAI) is a highly lethal lesion. A large number of victims die before obtaining emergency care. Thoracic endovascular aneurysm repair (TEVAR) is a less invasive method compared with open surgery and may change protocols for BAI treatment. This retrospective study was developed to evaluate the potential issues about thoracic endografting in the management of these patients. Twenty-seven patients with a BAI underwent aortic stent grafting. Intervention was preceded by the treatment of more urgent associated lesions in nine cases. In-hospital mortality was 7.4%. No paraplegia or ischemic complications developed because of the coverage of the left subclavian artery. In one case (3.2%), a type I endoleak was detected, proximal endograft infolding in two cases (7.4%) and endograft distal migration in further two cases were detected during follow-up (6-110 months). Thoracic endovascular aneurysm repair of BAI showed encouraging results in terms of perioperative mortality and morbidity. Concerns still remain about the potential mid- and long-term complications in younger patients.

Midterm results of proximal aneurysm sealing with the ovation stent-graft according to On-vs off-label use

Purpose: To compare the use of the Ovation stent-graft according to the ≥7-mm neck length specified by the original instructions for use (IFU) vs those treated off-label (OL) for necks <7 mm long. Methods: A multicenter retrospective registry (TriVascular Ovation Italian Study) database of all patients who underwent endovascular aneurysm repair with the Ovation endograft at 13 centers in Italy was interrogated to identify patients with a minimum computed tomography (CT) follow-up of 24 months, retrieving records on 89 patients (mean age 76.4±2.4 years; 84 men) with a mean follow-up of 32 months (range 24–50). Standard CT scans (preoperative, 1-month postoperative, and latest follow-up) were reviewed by an independent core laboratory for morphological changes. For analysis, patients were stratified into 2 groups based on proximal neck length ≥7 mm (IFU group, n=57) or <7 mm (OL group, n=32). Outcome measures included freedom from type Ia endoleak, any device-related reintervention, migration, and neck enlargement (>2 mm). Results: At 3 years, there was no aneurysm-related death, rupture, stent-graft migration, or neck enlargement. There were no differences in terms of freedom from type Ia endoleak (98.2% IFU vs 96.8% OL, p=0.6; hazard ratio [HR] 0.55, 95% CI 0.02 to 9.71 or freedom from any device-related reintervention (92.8% IFU vs 96.4% OL, p=0.4; HR 2.42, 95% CI 0.34 to 12.99). In the sealing zone, the mean change in diameters was −0.05±0.8 mm in the IFU group and −0.1±0.5 mm in the OL group. Conclusion: Use of the Ovation stent-graft in patients with neck length <7 mm achieved midterm outcomes similar to patients with ≥7-mm-long necks. These midterm data show that the use of the Ovation system for the treatment of infrarenal abdominal aortic aneurysm is not restricted by the conventional measurement of aortic neck length, affirming the recent Food and Drug Administration–approved changes to the IFU.

Mid- and Long-Term Results of Endovascular Treatment in Thoracic Aorta Blunt Trauma

Study Aim. Evaluation of results in blunt injury of the thoracic aorta (BAI) endovascular treatment. Materials and Methods. Sixteen patients were treated for BAI. Thirteen patients had associated polytrauma, 4 of these had a serious hypotensive status and 4 had an hemothorax. In the remaining 3, two had a post-traumatic false aneurysm of the isthmus and 1 had a segmental dissection. In those 13 patients a periaortic hematoma was associated to hemothorax in 4. All patients were submitted to an endovascular treatment, in two cases the subclavian artery ostium was intentionally covered. Results. One patient died for disseminated intravascular coagulation. No paraplegia was recorded. No ischemic complications were observed. A type I endoleak was treated by an adjunctive cuff. During the followup (1–9 years) 3 patients were lost. A good patency and no endoleaks were observed in all cases. One infolding and 1 migration of the endografts were corrected by an adjunctive cuff. Conclusion. The medium and long term results of the endovascular treatment of BAI are encouraging with a low incidence rate of mortality and complications. More suitable endo-suite and endografts could be a crucial point for the further improvement of these results.

Type IB and type III endoleak 8 years after endovascular aneurysm repair.

An 86-year-old man was admitted to our hospital for abdominal pain and underwent an AneurRx bifurcated endograft (Medtronic AVE, Sunnyvale, Calif) implantation 8 years earlier for a 7-cm-diameter abdominal aortic aneurysm (AAA). His comorbidities were chronic atrial fibrillation, diabetes, dyslipidemia, chronic renal failure, hypertension, severe chronic obstructive pulmonary disease, and coronary artery disease. This patient also underwent an appendicectomy, inguinal hernioplasty, and cholecystectomy. An expandible abdominal mass was found during a clinical examination. Doppler ultrasound imaging and a computed tomography scan showed a severe increase of AAA diameter to 11 cm, associated with a type IB endoleak from the right leg displaced into the aneurysmal sac itself and to a type III endoleak due to detachment of the contralateral leg (A-C). Similar patients reported in the literature underwent open or endovascular treatment. Our patient was assessed by the anesthesiologist and cardiologist as being in American Society of Anesthesiologist class IV and therefore unfit for surgical repair, so an endovascular approach was planned. Through a left transaxillary access, a hydrophilic guidewire was introduced first into the endograft main body and its right leg and, thereafter, was captured by means of an Amplatz GooseNeck (EV3, Plymouth, Minn) introduced through the right common femoral artery. This was exchanged with a stiff guidewire, and a right aorto-uni-iliac Zenith Cook endograft (Cook Inc, Bloomington, Ind) was deployed. After surgical exposure of the left common femoral artery, an endovascular plug (Iliac Plug Cook Zip-20) was inserted in the ipsilateral common iliac artery. A femoro-femoral crossover bypass was completed with a 7-mm external-supported polytetrafluoroethylene graft (Vascutek Ltd, Inchinnan, Scotland). The procedure was performed with spinal anesthesia, the operating time was 135 minutes, and the contrast medium amount was 250 mL. The patient’s postoperative period was uneventful and he was discharged after 8 days, with no worsening of renal condition. A computed tomography scan at 6 months showed a good result of the procedure, with no endoleak and reduction of the AAA diameter (D).