Nicola Troisi

Surgical treatment of visceral artery aneurysms: A 25-year experience

OBJECTIVE The aim of this study was to analyze our 25-year experience with surgical treatment of visceral artery aneurysms (VAAs), with particular attention paid to early and long-term results. MATERIALS AND METHODS From January 1982 to September 2007, 55 patients (32 males, 58%, and 23 females, 42%) underwent surgical treatment of 59 VAAs. Only one patient was treated with an endovascular procedure. Mean patient age was 59.3 years (range, 36-78 years). The site of aneurysmal disease was splenic artery in 30 (50.8%) cases, renal artery in nine (15.2%) cases, common hepatic artery in seven (11.9%) cases, pancreaticoduodenal artery in four (6.8%) cases, celiac trunk in three (5.1%) cases, superior mesenteric artery in two (3.4%) cases, and gastroduodenal, inferior mesenteric, middle colic and right gastroepiploic in one (1.7%) case for each artery. Two (3.6%) patients had multiple VAAs. In five (9.1%) patients, an abdominal aortic aneurysm coexisted. Early results in terms of mortality and major complications were assessed. Follow-up consisted of clinical and ultrasound examinations at 1 and 12 months, and yearly thereafter. Long-term results in terms of survival and aneurysm-related complications were analyzed. RESULTS In all but two cases, elective intervention in asymptomatic patients was performed. Two (3.6%) patients had a ruptured aneurysm (one pancreaticoduodenal artery and one middle colic artery). The one perioperative death was due to an acute pancreatitis in a patient operated on for a giant inflammatory splenic artery aneurysm, yielding a perioperative mortality rate of 1.8%. Two major complications (retroperitoneal hematoma and acute pancreatitis) were recorded. Mean duration of follow-up was 82.1 months (range, 0-324 months). Estimated 10-year survival rate was 79.5%. During follow-up two aneurysm-related complications occurred, with an estimated 10-year, aneurysm-related, complication-free survival rate of 75.2%. CONCLUSION In the era of minimally invasive therapeutic approaches, elective open surgical treatment of visceral artery aneurysms is safe and effective, and offers satisfactory early and long-term results.

Use of Abdominal Chimney Grafts is Feasible and Safe: Short-term Results

Purpose: To present our initial experience with the use of chimney grafts in endovascular aneurysm repair (EVAR) of abdominal aortic aneurysms (AAAs) with challenging anatomy. Methods: Among 390 EVAR cases performed at our institution between November 2008 and February 2010, 15 patients (all men; mean age 81.8 years) underwent EVAR with synchronous placement of chimney grafts. The chimney technique involved placing covered stents parallel to the main aortic stent-graft to preserve or rescue flow to aortic branch vessels while extending the proximal fixation zone. All patients presented with pararenal aortic aneurysms with short necks (between 0 and 10 mm long) that required either suprarenal clamping to tailor a proximal anastomosis in open repair or suprarenal fixation to anchor an endoprosthesis. Chimney grafts were implanted into 10 left renal and 5 right renal arteries. Results: The immediate technical success was 100%. One early type II endoleak due to retrograde flow from the inferior mesenteric artery was detected and is under surveillance. Mean follow-up was 6.8 months (range 1–13). One chimney graft occluded 45 days postoperatively; the patient underwent open thrombectomy of the left renal artery and iliorenal bypass. The creatinine value at discharge was 1.6 mg/dL, and resting renal scintigraphy showed 36% perfusion for the left kidney and 64% for the right kidney. During follow-up, no patient required hemodialysis; no aneurysm-related deaths were noted. Conclusion: This limited experience demonstrates that the use of abdominal chimney grafts is feasible and safe. Long-term results in larger patient cohorts are needed evaluate the utility of this alternative endovascular technique.

Evaluation of the Endurant stent graft under instructions for use vs off-label conditions for endovascular aortic aneurysm repair

BACKGROUND This study evaluated the early and intermediate results of endovascular aortic aneurysm repair (EVAR) using the Endurant stent graft (Medtronic Cardiovascular, Santa Rosa, Calif) in patients treated according to device-specific instructions for use (IFU) for the proximal aortic neck compared with those obtained in patients treated in an off-label (OL) situation. METHODS Between November 2007 and March 2010, 177 consecutive patients with abdominal aortic aneurysms (AAAs) were treated with the Endurant stent graft at our centers. The IFU for the Endurant stent graft included a proximal neck of 15 mm in length and <75° of angulation or 10 mm of neck length and <60° of angulation. The 121 patients (68.4%) operated on according to IFU were compared with 56 (31.6%) who underwent EVAR in OL circumstances to evaluate significant differences in demographics, intraoperative technical factors, and early (30 days) and intermediate outcomes (1 year). RESULTS Significantly more patients were aged >80 years in the OL group (37.5% vs 19%, P = .008), and they also had larger aneurysms (59 ± 10.6 vs 55.9 ± 10.8 mm, P = .05) and required a longer procedure time (69.3 ± 27.2 vs 60.8 ± 20.4 minutes, P = .02). At 30 days, the risk of type I endoleak was higher in the OL group (2 patients, 3.6% vs 0 in IFU), but this did not reach statistical significance (P = .09). The two groups were similar in rates of perioperative mortality, major morbidity, technical success, clinical success, complications, and reinterventions. At 1 year, there were no differences between the two groups in survival, freedom from any device-related reinterventions, and freedom from graft thrombosis. Estimated 1-year freedom from type I endoleak was 100% in the IFU group vs 93.3% in the OL group (P = .01). CONCLUSIONS In patients with both normal and complex anatomy of the proximal aortic neck, the Endurant stent graft obtained acceptable results, with no difference in survival, morbidity, or reinterventions. However, there was a greater risk of type I endoleak when OL indications were applied. Longer term follow-up is required to evaluate the effectiveness of this endograft in preventing late aneurysm-related complications.

Secondary Procedures After Aortic Aneurysm Repair With Fenestrated and Branched Endografts

Purpose To investigate the secondary procedures in patients with previous endovascular aortic repair by fenestrated or branched stent-grafts for aneurysms involving the renal and visceral vessels. Methods Between January 2001 and May 2010, 107 consecutive high-risk patients (97 men; mean age 73 years, range 50–86) with aortic aneurysms involving the renal and visceral arteries were treated with endovascular techniques. A custom-made Zenith graft was used in all patients. All secondary graft-related procedures performed in the perioperative period and during follow-up were analyzed. Estimates of survival, freedom from migration/type I endoleak, and freedom from any device-related secondary procedures were assessed with Kaplan-Meier analyses. Results The 30-day mortality rate was 1.9%. During follow-up (mean 25 months, range 1–94), 34 secondary procedures were performed in 28 (26.2%) patients for 6 (17.6%) limb graft stenoses/thromboses (5.6% of 107 cases), 8 (23.5%) in-stent visceral vessel stenoses/ occlusions (7.5% of 107 cases), 8 (23.5%) migrations/type I endoleaks with/without visceral stent fractures (7.5% of 107 cases), and 12 (35.3%) type III endoleaks (9.3% of 107 cases). The mean interval between the primary and secondary procedures was 12.9 months (range 1?68). In 26 (76.5%) of 34 cases, a secondary endovascular procedure was performed; in the remaining 8 (23.5%) cases, the complication was treated surgically. The secondary procedure was unsuccessful in 9 cases of visceral vessel compromise (failure to cannulation, stent fracture/migration, in-stent stenosis/occlusion). Estimated 3-year survival was 77%, while the 3-year rate for freedom from any device-related secondary procedure was 75.5%. Conclusion The incidence of early and late complications requiring a secondary procedure after treatment with fenestrated or branched devices was not negligible. Endoleak type III represented the most common cause for reintervention during follow-up. Secondary procedures performed for visceral vessel compromise had high rates of treatment failure. Accurate preoperative planning, the advent of new materials/techniques, and strict follow-up could be the key factors to improving the results of fenestrated or branched stent-graft interventions and to reduce the rate of secondary procedures.

Endurant stent-graft: a 2-year, single-center experience with a new commercially available device for the treatment of abdominal aortic aneurysms.

Purpose: To evaluate early and midterm results of the Endurant stent-graft in the treatment of abdominal aortic aneurysms (AAAs). Methods: From November 2007 to December 2009, 156 patients (142 men; mean age 73.6 years, range 51–90) were treated with the Endurant stent-graft at our center. More than half (106, 67.9%) had hostile proximal neck anatomy. Early (30-day) technical success, clinical success, major morbidity, and mortality rates were analyzed, as well as estimated 2-year survival, freedom from types I/III endoleak, freedom from graft thrombosis, freedom from any device-related reinterventions, and factors affecting 2-year freedom from types I/III endoleak. Results: Immediate intraoperative technical and clinical success was achieved in all cases. In 14 (9%) cases with a proximal neck <5 mm long, a “chimney” technique was used. At discharge, computed tomography demonstrated 2 (1.3%) type I endoleaks. At 30 days, 4 (2.6%) patients had died (2 were urgent cases); the 30-day major morbidity was 7.7%. The overall 30-day technical success and clinical success rates were 98.7% and 95.5%, respectively. During a mean 9-month follow-up (range 1–24), 3 patients died (one of them from AAA rupture). Estimated survival, freedom from types I/III endoleak, freedom from graft thrombosis, and freedom from any device-related reinterventions at 2 years were 94.7%, 96.9%, 97.8%, and 92.6%, respectively. Conclusion: The Endurant stent-graft seems to be safe and effective in endovascular aneurysm repair (EVAR), even in patients with hostile aortoiliac anatomy. However, perioperative and midterm complications occur, which could be explained by the expansion of indications for EVAR. Further studies are needed to evaluate the long-term results.

Endovascular Aortic Aneurysm Repair with the Endurant Stent-graft: Early and 1-year Results from a European Multicenter Experience

PURPOSE To assess preliminary results of the Endurant stent-graft, which was developed to treat patients with abdominal aortic aneurysms (AAAs) and challenging aortoiliac anatomy. MATERIALS AND METHODS From November 2007 to October 2008, 45 patients with AAAs were treated with the Endurant stent-graft in three European vascular centers. Thirty-eight of the 45 patients (84%) had a hostile anatomy of the proximal neck. Early (30 days), early midterm (6 months), and late midterm (1 year) results were analyzed in terms of technical success, clinical success, morbidity, and mortality. RESULTS Intraoperative immediate technical and clinical success was achieved in all cases. At completion angiography, a type II endoleak was detected in seven of the 45 patients (16%) and an iliac limb stenosis was diagnosed and successfully treated in five (11%). At discharge, computed tomography demonstrated a type I endoleak in one of the 45 patients (2.2%). At 30 days, a graft limb thrombosis was diagnosed (2.2%) and successfully treated. The 30-day overall technical and clinical success rates were 97.8% (44/45 cases) and 95.6% (43/45 cases), respectively. During follow-up (mean duration, 8 months; range, 5-16 months), the type I endoleak was successfully treated with an aortic extension. Estimated freedom from type I or III endoleak and repeat intervention at 1 year was 97.8% (44/45 cases) and 93.3% (42/45 cases), respectively. CONCLUSIONS The initial experience shows that the Endurant stent-graft appears to be effective in endovascular repair of AAAs in patients with hostile aortoiliac anatomy. This graft permits a broader group of patients to be treated with endovascular aneurysm repair; however, further studies are needed to evaluate the long-term results.

Pararenal and Thoracoabdominal Aortic Aneurysm Repair With Fenestrated and Branched Endografts: Lessons Learned and Future Directions

A totally endovascular approach to complex aortic aneurysms using fenestrated and branched stent-grafts is a technically demanding alternative to open surgical repair of thoracoabdominal and pararenal aneurysms. Complications of these complex endovascular reconstructions are varied, from dislocation of the stent-graft to occlusion of the target vessels. Based on our growing experience with these procedures, we reviewed the causes leading to secondary procedures after ≥100 branched/fenestrated stent-graft repairs and now propose several alterations to the technique that could improve the results of this approach to complex aortic aneurysm repair.

The Treatment of Isolated Iliac Artery Aneurysm in Patients with Non-aneurysmal Aorta

OBJECTIVES The aim of the study was to evaluate early and mid-term results of surgical repair of isolated iliac artery aneurysm (IAA) in patients with non aneurysmal abdominal aorta. METHODS From January 1996 to December 2006, 34 patients with IAA had elective surgery. In 32 cases open repair was performed. Two patients had endovascular repair using a tube endoprosthesis and internal iliac artery coil embolization. The diameters of the abdominal aorta and iliac arteries were measured preoperatively and during follow-up. Early and late results in terms of mortality, major morbidity, reinterventions and graft-related complications were recorded. Mean pre and postoperative diameters of abdominal aorta were compared. RESULTS The site of the IAA was the common iliac artery in 29 cases (10 bilateral), internal iliac artery in 4 cases and external iliac artery in 1 case. Preoperative mean abdominal aortic diameter was 22.2mm (SD 7.6). There were no perioperative deaths and two major complications (retroperitoneal bleeding and limb ischemia) occurred. At the median follow-up time of 24 months survival was estimated as 91%. No reinterventions, graft thrombosis and graft related complications occurred. There were no cases of abdominal aorta aneurysm development. Mean aortic diameter at the most recent imaging was 23.1mm, which was not significantly different from preoperative values (p=0.2). CONCLUSIONS Surgical treatment of IAAs provides good early and mid-term results. During mid-term follow-up the diameter of abdominal aorta remains stable, suggesting IAA may be a localized aneurysmal disease.

Preoperative Cardiac Assessment in Patients Undergoing Aortic Surgery: Analysis of Factors Affecting the Cardiac Outcomes

BACKGROUND The purpose of this study was to evaluate the effectiveness of a standardized preoperative cardiac assessment in reducing the rate of perioperative cardiac complications in patients undergoing aortic surgery, paying particular attention to the analysis of the factors affecting perioperative cardiac outcomes. METHODS Between January 2005 and August 2008, a total of 531 elective interventions for abdominal aortic aneurysms were performed at our institution. All patients underwent preoperative evaluation on an outpatient basis, which included a standardized cardiac assessment protocol to evaluate perioperative cardiac risk. A surgical (open or endovascular) intervention was performed in all patients and perioperative (<30 days) results in terms of overall and cardiac mortality and morbidity rates were recorded. RESULTS Preoperative electrocardiogram, transthoracic echocardiography, and cardiology consultation were performed in all patients. In 348 cases (65.5%), further evaluation of cardiac functional capacity with noninvasive stress testing was recommended. A positive noninvasive stress test was noted in 86 (24.7%) of 348 patients and coronary angiography was performed in 34 (39.5%) of 86 patients. Thirteen of these patients underwent successful coronary revascularization (11 percutaneous transluminal coronary angioplasty, two coronary artery bypass graft) before vascular surgery. Thirty-day overall rate and cardiac mortality rate were 1.1% and 0.6%, respectively, and 30-day overall and cardiac morbidity rates were 11.5% and 6.8%, respectively. Univariate analysis demonstrated that in patients aged >80 years, chronic renal failure, congestive heart failure, valvular heart disease, positive noninvasive stress testing, and open surgical treatment significantly affected 30-day cardiac morbidity; however, only valvular heart disease and positive noninvasive stress testing maintained their significance with multivariate analysis (p = 0.005; 95% CI, 1.6-14.4; and p = 0.02; 95% CI, 1.2-8.1, respectively). None of the examined factors significantly affected 30-day cardiac mortality. CONCLUSION In our experience, the use of a routine preoperative cardiac assessment allowed us to obtain satisfactory perioperative results in patients undergoing abdominal aortic surgery. Very few patients, however, require cardiac revascularization before abdominal aortic surgery. Patients with positive stress test may benefit from an endovascular treatment if anatomically feasible.

Carotid endarterectomy in female patients

OBJECTIVES To evaluate early and late results of carotid endarterectomy (CEA) in female patients in a large single center experience. METHODS Over a 12-year period ending in December 2007, 4009 consecutive primary and secondary CEAs in 3324 patients were performed at our institution. All patients were prospectively enrolled in a dedicated database containing pre-, intra-, and postoperative parameters. Patients were female in 1200 cases (1020 patients; Group 1) and male in the remaining 2809 (2304 patients, Group 2). Early results in terms of intraoperative neurological events and 30-day stroke and death rates were analyzed and compared. Follow-up results were analyzed with Kaplan Meier curves and compared with log-rank test. RESULTS Patients of Group 1 were more likely to have hyperlipemia, diabetes, and hypertension; patients of Group 2 were more likely to be smokers and to have concomitant coronary artery disease (CAD) and peripheral arterial disease (PAD). There were no differences in terms of clinical status or degree of stenosis. Patients of Group 2 had a significantly higher percentage of contralateral carotid artery occlusion than patients in Group 1 (6.9% and 3.9%, respectively; P < .001). Thirty-day stroke and death rates were similar in the two groups (1.2% for both groups). Univariate analysis demonstrated the presence of CAD, PAD, diabetes, and contralateral carotid artery occlusion to significantly affect 30-day stroke and death rate in female patients. At multivariate analysis, only diabetes (odds ratio [OR] 3.6, 95% confidence interval [CI] 0.1-0.9; P = .05) and contralateral occlusion (OR 7.4, 95% CI 0.03-0.6; P = .006) were independently associated with an increased perioperative risk of stroke and death. Median duration of follow-up was 27 months (range, 1-144 months). There were no overall differences between the two groups in terms of survival, freedom from ipsilateral stroke, freedom from any neurological symptom, and incidence of severe (>70%) restenosis. In contrast to male patients, univariate and multivariate analysis demonstrated that female patients with diabetes or contralateral occlusion had an increased risk of developing ipsilateral neurological events during follow-up. CONCLUSIONS Female sex per se does not represent an adjunctive risk factor during CEA, with early and long term results comparable to those obtained in male patients. However, in our study we found subgroups of female patients at higher surgical risk, requiring careful intra- and postoperative management.