Michalis Peroulis

Standard endovascular treatment of abdominal aortic aneurysms in patients with very short proximal necks using the Endurant stent graft

OBJECTIVE This study evaluated and compared the midterm results of endovascular aortic aneurysm repair with the Endurant (Medtronic Inc, Santa Rosa, Calif) stent graft system in off-label use in patients with short (<10 mm) proximal aortic necks and in patients treated according to device-specific instructions for use. METHODS This was a case-control (2:1) single-center retrospective analysis of prospectively collected data performed between September 2008 and December 2012. Analysis identified 19 elective patients with short (<10 mm) proximal necks and mild angulations (≤45°) treated with the Endurant stent graft and 38 patients matched for age, sex, and aneurysm diameter with proximal aortic necks ≥10 mm in length who met the instructions for use. End points included technical and clinical success and freedom from any secondary intervention, any type of endoleak, and aneurysm-related death. RESULTS The short-neck group was a mean ± standard deviation age of 71.7 ± 8.9 years, 84% were men, and their mean infrarenal aortic neck length was 6.1 ± 1.2 mm. Mean suprarenal and infrarenal angles were 110° ± 10.4° and 170° ± 15.4°, respectively. Aortic neck diameters were similar between the groups (26.6 ± 3.8 vs 25.7 ± 3.7 mm; P = .36). Primary technical success was achieved in all cases. Off-label patients were more likely to require additional proximal cuff deployment to successfully obtain a seal (21% vs 3%; P = .04). The two patient groups were similar in rates of perioperative mortality, morbidity, and complications. Mean follow-up of 24 ± 12 months revealed no differences in clinical success, freedom from reintervention, and aneurysm-related death. No type I endoleaks were observed in either group during the follow-up period. CONCLUSIONS The Endurant stent graft system applied off-label in patients with very short aneurysm necks (<10 mm) with mild angulation showed acceptable treatment results. These midterm results might suggest its use in carefully selected patients with very short neck anatomy. Long-term data are needed to verify the observed durability of the Endurant stent graft.

In endovascular aneurysm repair cases, when should you consider internal iliac artery embolization when extending a stent into the external iliac artery?

A best evidence topic was constructed according to a structured protocol. The question addressed was whether internal iliac artery (IIA) embolization is necessary for achieving the best clinical outcome in all patients when extension of the stent graft to the external iliac artery is required. Altogether more than 400 papers were found using the reported search, of which 5 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. There is a significant gap in the current literature regarding the subset of patients that may benefit from an IIA embolization during endovascular aneurysm repair (EVAR) as indications have not been clearly defined. There are several situations concerning a small number of patients, that IIA embolization might be beneficial in preventing endoleak not only to the common iliac artery but also to the aortic aneurysmal sac. For the majority of patients requiring extension of the stent graft to the external iliac artery, the current evidence, even retrospective in nature and reporting on small numbers of patients, shows that IIA embolization seems to be associated with worse clinical outcome, mostly raising the risk for new-onset buttock claudication. It seems that not all patients require embolization, as IIA coverage solely by the stent graft was not associated with a significant higher rate of type II endoleak in either study. Furthermore, coil embolization in the largest study so far was associated with higher procedure and fluoroscopy time and amount of contrast media, facts that should not be neglected. However the above-mentioned results should be taken into account with caution, as all studies were retrospective and reported on small number of patients.

Analysis of Effects of Fixation Type on Renal Function After Endovascular Aneurysm Repair

Purpose To report a prospective nonrandomized study comparing the effects of suprarenal (SR) vs. infrarenal (IR) stent-graft fixation on renal function in patients undergoing endovascular aneurysm repair (EVAR) for abdominal aortic aneurysm (AAA). Methods Patients with AAA undergoing elective EVAR between June 2008 and June 2010 were eligible for the comparative study of fixation method on renal function. Patients with impaired renal function [estimated creatinine clearance (eCrCl) <30 mL/min] or a history of renal impairment were not eligible. Renal function was assessed by measuring serum creatinine (SCr) and total proteins and microalbumin in the urine preoperatively, on postoperative day 1, and at 1, 6, and 12 months. The eCrCl was calculated using the Cockcroft-Gault formula. A standard preoperative hydration protocol was followed in all patients, and stent-graft choice was at the operators discretion. Of 116 patients undergoing elective EVAR in the study period, 16 were ineligible, leaving 100 patients (95 men; median age 74 years) enrolled in the study (49 SR and 51 IR). Results There was no statistically significant difference between the groups in the prevalence of any risk factor, the baseline SCr and eCrCl values, contrast usage, or procedure duration. At the postoperative measurement, there was no significant deterioration of renal function in either group, although total urinary proteins increased significantly in both groups (IR p=0.01, SR p<0.001). At the 12-month follow-up, patients in the IR group had no significant alteration in any marker vs. baseline, while patients in the SR group had significant alterations in SCr (p=0.001), eCrCl (p<0.001), and microalbumin (p=0.04) in urine. The number of patients with a >20% decrease in eCrCl was not significantly different between the groups. No patient had an adverse renal event. Conclusion Deterioration in renal function was observed 12 months after EVAR in patients receiving a stent-graft with suprarenal fixation, even though this did not seem to increase the likelihood of postoperative renal impairment. Furthermore, suprarenal fixation may be responsible for progressively significant proteinuria. Further studies are needed to determine the long-term impact of suprarenal fixation on renal function and investigate the potential risk of progressive renal disease in relation to type of fixation.

Endovascular repair of blunt axillo-subclavian arterial injuries as the first line treatment.

AIM To report and analyse our results regarding the endovascular management of blunt axillo-subclavian arterial injuries as the first line treatment. METHODS During an eight-year period, seven patients (mean age 56.4±14.1 years, all males) with blunt traumatic axillo-subclavian arterial injuries were presented to the emergency department. All patients suffered also from concomitant other injuries and had a supraclavicular haematoma along with diminished or absent upper limb peripheral pulses, while computed tomography angiography set the diagnosis. RESULTS The endovascular procedure was technically successful in all patients. No procedure-related complication was encountered during the in-hospital stay, while none of the patients died. The median hospital stay was 22 days (range 12-46). During a follow-up period spanning an average of 27 months (range 6-44 months) there was one stent-graft thrombosis at 12 months in an otherwise asymptomatic patient that required no further intervention. CONCLUSION Endovascular technique seems to constitute a reliable approach for treating blunt axillo-subclavian arterial injuries in the emergent setting. Despite uncertainties in patient selection and optimal management algorithms, it seems that endovascular approach could be the first line treatment for such injuries. Accumulation of data on larger number of patients with longer follow-up is warranted to further define the value of this therapeutic modality in the trauma setting.

Safe and fast proximal aortic control using an aortic balloon through direct graft puncture for the explantation of an abdominal endograft with suprarenal fixation

The late removal of an abdominal aortic endograft is technically challenging and can be associated with significant blood loss, especially when a graft with active suprarenal fixation is involved. The main issue in safe explantation of the endograft is control of the aorta above the proximal fixation site. We report an adjunctive technique for the safe and fast proximal control of the suprarenal aorta using an aortic balloon. The endograft is directly punctured and an aortic balloon is deployed and inflated above the fixation site in the supracoeliac aorta. The time for supracoeliac control in our 2 patients was <5 min. This simple technique offers a safe and fast aortic control during the removal of the endograft, especially when active suprarenal fixation is used, avoiding the risks from a technically demanding dissection in a potentially inflammatory region.

Endovascular Treatment of Chronic Total Occlusions of the Iliac Arteries: Early and Midterm Results

BACKGROUND To examine the effects of endovascular therapy on the treatment of chronic total occlusions (CTOs) of the iliac arteries. METHODS We analyzed a cohort of 48 patients (56 limbs) who were treated by endovascular means for iliac artery CTOs during a period of 4 years in 2 vascular surgery centers in Greece. The data were collected retrospectively and were statistically analyzed to report on technical success, morbidity, mortality, primary and secondary patency, and limb salvage through different patient and/or lesion stratifications. RESULTS Recanalization was accomplished without assisting devices, and primary stenting was always performed. The technical success of the endovascular treatment reached 91%. Patients experienced 4.2% major morbidity and 2.1% mortality rate. Mean ankle-brachial pressure index increased from 0.43 ± 0.12 preoperatively to 0.89 ± 0.11 postoperatively. A median improvement by 3 Rutherford clinical categories was recorded at the first-month follow-up. The estimated limb salvage rate for patients suffering from critical limb ischemia (CLI) was 90.9% at 36 months. Kaplan-Meier analysis estimation for overall primary and secondary patency rate of the treated lesions was 91.4% and 95.3%, respectively at 36 months. There were no statistically significant differences in primary and secondary patency rate between patients in different clinical stages (CLI versus intermittent claudication), as well as between CTO lesions of different Trans-Atlantic Inter-Society Consensus (TASC) categories (TASC B versus TASC C versus TASC D). There was not statistical significant difference between the technical success of TASC B, C, and D lesion groups. CONCLUSIONS The endovascular treatment of iliac CTOs seems to be safe and feasible. The technical success of the procedure could be high, whereas primary and secondary patency rates seem to be optimal, with remarkable limb salvage rate and overall clinical improvement. A potential shift to an endovascular-first approach for such lesions might be currently justified.

Initial Clinical Experience with the Endologix AFX Unibody Stent Graft System for Treating Patients with Abdominal Aortic Aneurysms: A Case Controlled Comparative Study

Purpose The newly designed unibody AFX endograft system for endovascular aortic aneurysm repair is the only graft with anatomical fixation to the aortic bifurcation in comparison to most other grafts that use the infrarenal neck as the main fixation point. The aim of this study was to assess the preliminary results of the AFX stent-graft system used with infrarenal aortic component and compare them with those obtained in patients treated with a well established endograft of the same material and pure infrarenal fixation as the Gore Excluder. Materials and Methods A retrospective analysis of prospectively collected data from March 2014 to December 2014 identified 10 elective abdominal aortic aneurysm patients treated with the AFX endograft, in comparison to a matched group of 20 patients treated with the Excluder stent-graft. Endpoints included technical and clinical success, freedom from any secondary intervention, any type of endoleak and aneurysm related death. Results Primary technical success was achieved in all patients and no 30-day device related complications or deaths were occurred. The two groups were similar in terms of radiation burden, contrast media, duration of the procedure, post implantation syndrome and in-hospital stay. During a median follow-up period of 23 months (range, 18–26 months) there were no differences in clinical success, freedom from reintervention and aneurysm related death. No type I endoleak was observed in either group. Five of the 6 type II endoleaks (1 in the AFX and 4 in the Excluder group) spontaneously resolved, while in only one patient (Excluder) the endoleak remained without however any change in aneurysm sac diameter (log rank=0.34). Conclusion The initial experience with the AFX stent graft system is promising, with successful aneurysm exclusion and good short-term results. Further and larger studies are needed to fully evaluate the sort as well as the long-term results.

The effect of increasing operator experience on procedure-related characteristics in patients undergoing carotid artery stenting

Objectives To evaluate the efficacy and safety of carotid artery stenting for the treatment of severe carotid artery disease in our department and to investigate the effect of increasing operator experience on perioperative and procedure-related characteristics. Methods From January 2007 to February 2015 200 patients underwent 207 endovascular procedures for carotid artery stenosis. Of all, 113 arteries (56.5%) were symptomatic. Significant changes across time were calculated with the use of Change Point analysis using bootstrap and mean squared error estimates. Results The technical success was 98.6% (204/207 cases). Thirty-day neurological events included stroke in four patients (2%) and transient ischemic attack in two (1%). None of the patients died during the first 30 days. The most significant change of radiation duration occurred after the 33rd patient with a decrease from 25.31 min to 12.31 min, while for the total operative time that change occurred between the 31st and 33rd patient where mean operation time decreased from 88.89 min to 49.22 min. The most significant change of contrast media used occurred at the 40th patient with a decrease from 91.58 ml to 62 ml. During a mean follow-up period of 42 ± 20.02 months none of the patients experienced any cerebrovascular event. There was one case of significant recurrent stenosis, which was successfully treated by endovascular means. Conclusions Endovascular treatment of carotid artery stenosis performed in a single center with the use of a cerebral protection device seems to consist a safe therapeutic choice with acceptable results, within the referenced benchmarks proposed in the latest guidelines. Certain perioperative parameters such as the amount of contrast media used, the fluoroscopy and operation time, seem to decline overtime indicating increasing operator’s experience. A number of performed cases above 40 was related to the significant decrease of those parameters and may represent the learning curve of the procedure.

Endovascular Treatment of an Aneurysm Rupture into the Inferior Vena Cava

The overall mortality in patients with AAA and associated ACF has been reported as high as 67% [2]. This high rate could be partially attributed to the excessive blood flow through the fistula, usually resulting to central venous hypertension, refractory congestive heart failure and multi organ failure [1-3]. ACF can also present in combination with retroperitoneal rupture, having a much worse prognosis [2, 3].

An Uncommon, Life-Threatening, Traumatic Hematoma in the Neck Area

It is well known that blunt neck trauma, when compared to a penetrating injury in the same anatomical area, is very rare. We report a case of an 81-year-old Caucasian woman with a blunt life-threatening neck trauma due to a bully goat. Although rare, direct evaluation should always be done in these cases because any misinterpretation may result in unfavorable outcomes. We have to highlight that close medical attention and prompt surgical treatment should be always considered in order to avoid dramatic consequences.