Nazzareno Stella

Cerebral Embolization during Transcervical Carotid Stenting with Flow Reversal: A Diffusion-Weighted Magnetic Resonance Study

Transfemoral filter-protected carotid artery stenting (CAS) has emerged as a valid alternative to carotid surgery. To overcome the drawbacks of femoral access for CAS and reduce embolic load, some have proposed cervical access with internal carotid artery (ICA) flow reversal. In a series of patients at high risk for femoral access who underwent transcervical CAS with ICA flow reversal, we report clinical outcome and intraoperative embolization rates measured by diffusion-weighted magnetic resonance imaging (DW-MRI). A series of 48 patients were selected for transcervical CAS with carotid flow reversal from September 2004 to July 2007. The indications used for this technique were age >or=80 years, severe aortic and epiaortic vessel tortuosity, widespread calcification of aortic arch or epiaortic vessels, severe aortoiliac occlusive disease, large abdominal aortic aneurysm, and aortobifemoral prosthesis. During the procedure, no adjunctive maneuvers such as external carotid artery balloon occlusion were used. Of the 48 patients, 43 underwent preoperative and postoperative cerebral DW-MRI. The death/stroke rate in the 48 patients was 2.1% (one transient ischemic attack, one minor stroke, and no deaths). None of the procedures led to carotid dissections or access-site complications. Of the 43 patients who underwent DW-MRI, 16 new ischemic lesions were disclosed in six patients (13.9%), four (9.3%) of whom remained asymptomatic. All ischemic lesions were ipsilateral to the treated carotid artery. In patients at high risk for the transfemoral approach, transcervical carotid stenting with flow reversal achieves good technical and clinical results and seems able to reduce the incidence of postoperative DW-MRI ischemic lesions previously reported for transfemoral filter-protected CAS.

Doppler ultrasonography and exercise testing in diagnosing a popliteal artery adventitial cyst.

We describe popliteal arterial adventitial cystic disease which causes intermittent claudication in a young athletic man, with atypical manifestation, without loss of foot pulses on knee flexion nor murmur in the popliteal fossa. The findings obtained from Magnetic Resonance Imaging were non-diagnostic. The diagnosis resulted from Echo-Doppler ultrasonography along with peak exercise testing. Ultrasonography also provided useful physiopathological informations suggesting that a popliteal artery adventitial cyst can become symptomatic if muscle exertion increases fluid pressure within the cyst, enough to cause hemodynamically significant endoluminal stenosis. Rapid diagnosis is essential to prevent progressive claudication threatening limb viability. To guarantee this professional sportsman a reliable and durable outcome, instead of less aggressive management, we resected the involved arterial segment and interposed an autologous saphenous-vein graft.

Cervical Access for Filter-protected Carotid Artery Stenting: A Useful Tool to Reduce Cerebral Embolisation

BACKGROUND Filter-protected transcervical carotid artery stenting (CAS) has been suggested to reduce the intraoperative cerebral embolisation observed during transfemoral CAS. We therefore evaluated clinical outcome and incidence of ischaemic lesions at diffusion-weighted magnetic resonance imaging (DW-MRI) after transcervical and transfemoral CAS. METHODS From March 2007 to May 2009, we performed filter-protected CAS in 135 patients with symptomatic (30%) or asymptomatic (70%) carotid stenosis above 70% and below 95%. In 44 patients with risky femoral access or unfavourable aortic arch anatomy, access to common carotid artery was achieved by a small cervical incision. In another 91 procedures we used a classic percutaneous femoral access. Preoperative and postoperative DW-MRI scans were obtained after 111 procedures (82%) - 35 transcervical and 76 transfemoral. RESULTS The incidence of clinical events (transient ischaemic attack (TIA) and stroke) was 2.3% after transcervical CAS and 19.8% after transfemoral CAS (P<0.01), without any deaths. DW-MRI disclosed new ischaemic lesions in five patients (5/35, 14.3%) after transcervical CAS and in 28 patients (28/76, 36.8%) after transfemoral CAS (P=0.015). All ischaemic lesions depicted after transcervical procedures were ipsilateral to the treated artery. CONCLUSIONS Transcervical filter-protected CAS, compared with classic percutaneous procedures, seems to reduce clinical events and DW-MRI ischaemic damage and may be useful in selected patients.

Endovascular treatment of common carotid artery dissection via the superficial temporal artery.

Purpose: To describe the endovascular treatment of an iatrogenic common carotid artery (CCA) dissection using the superficial temporal artery (STA) as the principal access. Technique: An 83-year-old man with a post–carotid endarterectomy left CCA dissection was admitted for a transient ischemic attack involving the left cerebral hemisphere that occurred despite proper anticoagulation. After excluding redo surgery and transfemoral stenting (owing to a partially compromised aortobifemoral bypass graft), stenting of the left CCA dissection was planned using a right transbrachial approach, with the left STA as an additional access. However, intraoperative angiography showed an acute angle between the innominate artery and left CCA, so the STA was used as the primary access route owing to its straight course and 4-mm diameter. The 9-x40-mm self-expanding stent was inserted via a 5-F sheath in the STA and deployed directly at the CCA dissection. The procedure was successful, and all vessels involved were patent at 6-month follow-up. Conclusion: In selected cases, the superficial temporal artery may represent a valid alternative approach for the endovascular treatment of short CCA dissections.

Trans-Atlantic Inter-Society Consensus II C and D iliac lesions can be treated by endovascular and hybrid approach: a single-center experience.

Purpose: To evaluate the long-term results of endovascular and hybrid treatment in patients with Trans-Atlantic Inter-Society Consensus (TASC) II type “C” and “D” aortoiliac lesions and to highlight, in contrast to TASC II guidelines, the importance to analyze individually the lesions of a single iliac axis. Methods: From January 2008 to December 2012, 50 patients with TASC II type C and D aortoiliac lesions underwent endovascular or hybrid treatment. In 38 patients (76%), the lesions were treated by endovascular approach, while in 12 (24%) patients surgical treatment was adopted. All patients underwent a postoperative surveillance program at 1, 3, and 6 months for the first year and every 6 months thereafter. Results: Technical success was achieved in all patients (100%). The postoperative complication rate was 4%. Primary patency rate was 93.3% at 1 year, 90.2% at 2 years, and 86.6% at 3 years. Cumulative secondary patency rate was 97.7% at 1, 2, and 3 years. Survival after 1 and 2 years was 94.8% and after 3 years was 91.1%. Limb salvage was 100% for the entire period of follow-up. Conclusions: In contrast to TASC II guidelines, the endovascular or hybrid treatment should be considered a valid approach for type C and D lesions. The hybrid treatment, in selected cases, is an effective method to improve the runoff, which plays a key role in the success of the treatment of multilevel stenoocclusive lesions. In TASC II C to D iliac lesions, a specific overview of each axis is necessary in order to select the most appropriate treatment.

Endotension-related aortic sac rupture treated by endograft relining

Endovascular aortic aneurysm repair is an effective alternative to open surgical repair in high risk patient. Endotension is an unpredictable late and rare complication of EVAR. Clinical significance and choice of technique for treatment are controversial. At present, there are no cases of endotension-related aneurysmal sac rupture reported in literature, altough it is frequently associated with late surgical conversion. In this case report is described a case of a patient treated with a first generation Gore Excluder™ endograft for abdominal aortic aneurysm, with late aneurysmal sac enlargement without evidence of endoleak and subsequent contained rupture without anemia and shock. We have successfully treated the patient by endovascular procedure, through bilateral percutaneous femoral approach, with relining technique. Three years CT scan follow-up showed the endograft patency and size sac reduction.

Aortic arch catheterization during transfemoral carotid artery stenting: an underestimated source of cerebral emboli.

Abstract Cerebral embolization is still a major concern in patients undergoing transfemoral carotid artery stenting. Intraoperative transcranial Doppler (TCD) monitoring and diffusion-weighted magnetic resonance imaging (DW-MRI), two techniques currently used to study this phenomenon, have provided data suggesting the importance of aortic arch catheterization in determining the overall embolic load observed during this procedure. In order to reduce this cerebral embolization, some Authors have proposed the performance of carotid artery stenting through a cervical access, either surgical or percutaneous. We review in this article the available TCD and DW-MRI data supporting transcervical CAS, along with its clinical results.

Hybrid Treatment for Thoracoabdominal Aortic Aneurysms in Patients with Marfan Syndrome

Marfan syndrome is a heritable disorder of connective tissue leading to aortic aneurysms and other cardiovascular complications associated with reduced life expectancy. Although contemporary management of ascending aortic disease requires open surgical reconstruction, the combined retrograde visceral revascularization and endovascular exclusion (hybrid procedure) of entire thoracoabdominal aorta has been introduced for the management of descending thoracic and abdominal aortic pathology. The present experience reports 2 cases of thoracoabdominal aortic aneurysms, in Marfan patients, previously submitted to major cardiovascular surgical procedures, through a hybrid approach.

Emergent Fully Endovascular Treatment of a Free Ruptured Thoracoabdominal Aneurysm

To present a case of successful emergency complete endovascular repair of a ruptured type IV thoracoabdominal aortic aneurysms (TAAA) through chimney technique with off-the-shelf devices. A 64-year-old man with a free ruptured type IV TAAA. Open access was obtained at both common femoral arteries, both axillary arteries, and left common carotid artery. Covered stent grafts were located undeployed into the target arteries. An endoprosthesis was released in the suprarenal aorta, and soon after, covered stents were deployed in renal arteries and superior mesenteric artery. Type Ib and II endoleaks required an adjunctive endovascular treatment. Total endovascular repair with chimney technique may be the only life-saving option in patients unfit for open surgery and is effective in sealing the aneurysm and maintaining blood flow to the aortic branches.

A Double Nellix and Chimney Covered Stents: Challenging Treatment of Pararenal Aortic Aneurysm

A 77-year-old male patient presented with a symptomatic, 66-mm pararenal aortic aneurysm. The patient was classified as unsuitable for open surgery due to significant comorbidities. Fenestrated or branched endografts were contraindicated due to the poor iliac access (6 mm diameter). A double Nellix with chimney endovascular aneurysm sealing (ChEVAS) technique was selected to exclude the pararenal aortic aneurysm and to preserve renal arteries and the superior mesenteric artery. Technical preplanning considered the ideal proximal landing zone to be close to the origin of the almost occluded celiac trunk and the distal common iliac arteries as the ideal distal landing zone. The total length of the aorta to cover was estimated as >180 mm, requiring 2 aortic EVAS systems, bilaterally overlapped. Technical success was achieved, and the patient was discharged on postoperative day 8 in good general condition. Successful aneurysm exclusion and target vessel patency without endoleak or stent-graft kinking or migration were confirmed at angio-computed tomography at 6 months.