P. Frigatti

Synchronous carotid endarterectomy and retrograde endovascular treatment of brachiocephalic or common carotid artery stenosis.

OBJECTIVES To retrospectively evaluate the safety and the long-term results of retrograde brachiocephalic and common carotid angioplasty and stenting (AS) performed for >70% stenosis synchronously with the carotid endarterectomy (CEA). PATIENTS Sixteen patients operated between April 1999 and March 2002. RESULTS 14/16 procedures were successful. There was no neurological morbidity or mortality. Per-operative angiography showed the optimal stent positioning and patency of both proximal and distal arteries in all patients. In the follow-up, all patients showed patency of the treated vessels without restenosis and the absence of any cerebrovascular symptoms. CONCLUSION Intra-operative retrograde AS combined with CEA is an effective, safe and durable alternative to conventional surgery when a tandem significant proximal lesion is identified in a patient with an high grade carotid stenosis.

Hybrid endovascular treatment of aneurysm degeneration in a rare right-aortic arch anomaly with Kommerell diverticulum

We present a hybrid endovascular approach to a 6.5-cm aneurysm of the right-sided aortic arch with an aberrant left subclavian artery arising from a Kommerell diverticulum, connected to the left pulmonary artery through the ligamentum arteriosum. The two-step procedure consisted of a bilateral carotid-subclavian bypass, followed by an ascending aorta-bicarotid bypass and completed by an endovascular exclusion of the aneurysms by covering the whole aortic arch and its branches. The patient had no complications and is asymptomatic 21 months after surgery. Hybrid procedures may be helpful in complex aortic arch pathologies, reducing complications of challenging open surgery.

Carotid artery endarterectomy in patients with contralateral carotid artery occlusion: Perioperative hazards and late results

The aim of this study was to analyze and compare the perioperative hazards and late results of internal carotid endarterectomy (CEA) in patients with and without contralateral internal carotid artery occlusion. From March 1980 to April 1990, 375 consecutive patients underwent 439 CEAs at the First Department of Vascular Surgery of Padova Medical School. Patients were divided into two groups; group 1 (61 patients) had contralateral internal carotid artery occlusion and group 2 (314 patients) did not (378 CEAs, 64 bilateral). Indications for CEA were similar in both groups. The only significant difference in patient characteristics was a higher rate of previous stroke in group 1 (11% vs. 3%,p< 0.001). General anesthesia, continuous EEG monitoring, selective intraluminal shunt, and arteriotomy closure with a polytetrafluoroethylene patch (PTFE) were used routinely in both groups. An intraluminal shunt was inserted more frequently in group 1 than in group 2 (69% vs. 17%,p<0.001). Major perioperativestroke occurred in one patient in each group (1.7% vs. 0.31%, respectively; NS). Early fatal stroke rates were 0% and 0.95% in groups 1 and 2, respectively (NS). All patients had neurologic examinations and duplex scans every 6 months (range 6 to 118 months; mean 42 months). Kaplan-Meier survival curves were virtually identical in the two groups; the majority of deaths were caused by myocardial infarction and cancer. There were no stroke-related deaths in group 1 as compared with 8.2% in group 2 (NS). New neurologic symptoms appeared in 4.7% of patients in group 1 and 6% in group 2 (NS) whereas the late stroke rates were 0% and 3.1%, respectively (NS). Restenosis was observed in two and three patients in groups 1 and 2, respectively (NS). In conclusion, CEA for ulcerated or stenotic lesions of the internal carotid artery in patients with contralateral carotid occlusion is associated with very low early and long-term neurologic morbidity and mortality, similar to findings in patients who undergo CEA with a patent contralateral carotid artery.

Thoracic aorta endograft as an adjunct to resection of a locally invasive tumor: A new indication to endograft

Covered stent grafts are currently used for arterial aneurysm exclusion, aortic dissection, or peripheral occlusive disease. A new indication to endograft was applied to perform resection of the thoracic aorta for infiltration of an adjacent lung cancer into the vessel wall, avoiding a major vascular intervention for aortic graft interposition associated with tumor resection.

Influence of localized edema on whole-body and segmental bioelectrical impedance

OBJECTIVE Tetrapolar whole-body (hand-foot) bioelectrical impedance (Z-body) is used in body composition analysis assuming homogeneous soft tissue hydration. Limbs and trunk contribute to Z-body by 90% and 10%, respectively. We determined the effect on Z-body of an edema localized in one leg. METHODS Resistance (R) and reactance (Xc) components of Z vector were measured at 50 kHz (BIA-101, RJL Systems, Akern, Italy) in 20 adult male patients without edema, before and 3 d after a femoropopliteal bypass that induced pitting edema in the leg. Z-body was measured from hand to foot on the right and left sides. Z from the leg (Z-leg) was measured from the pair of electrodes on the foot and the other pair on the trochanter. Data were analyzed with the vector bioelectric impedance analysis (Vector BIA) method (Piccolis RXc graph with 95% confidence ellipses). RESULTS Before surgery, the positions of the mean Z-body and Z-leg vectors from either side of the body were not significantly different (overlapping 95% confidence ellipses). After surgery, the mean Z-leg and Z-body vectors from the side without edema did not change position in the RXc plane with respect to the presurgery position. In contrast, the mean Z-leg and Z-body vectors of the body side with edema significantly (P < 0.05) shortened according to the Vector BIA patterns of fluid accumulation. CONCLUSION Z-body in the side of the body without edema is not sensitive to the edema localized in the leg on the opposite side and therefore can be used in the assessment of body composition in patients with edema in one leg.

Intentional coverage of the left subclavian artery during endovascular repair of traumatic descending thoracic aortic transection

OBJECTIVE This single-center, prospective study aimed to investigate the technical success and outcome of intentional coverage of the left subclavian artery (LSA) in patients undergoing thoracic endovascular aortic repair (TEVAR) for traumatic rupture of the aortic isthmus at a tertiary care medical center. METHODS From January 2005 to June 2011, patients who presented with traumatic aortic transection underwent TEVAR with coverage of the LSA when the distance between the artery and the rupture was <2 cm. At 12, 24, and 72 hours postoperatively, clinical and neurologic evaluation including transcranial Doppler insonation of the brachial artery was performed. A decrease in peak systolic velocity (PSV) >60% with respect to the contralateral one was considered relevant. Functional status of the left arm was evaluated using a provocative test. Thoracoabdominal computerized tomographic angiography was performed postoperatively at 3-, 6-, and 12-month follow-up. RESULTS Thirty-one patients (mean age 35 years) underwent emergency TEVAR for traumatic aortic transection with intentional LSA coverage during the study period. In four cases (12.9%) coverage was partial. Two patients (6.4%) died during the postoperative period due to associated lesions. No signs of vertebrobasilar insufficiency, stroke, or paraplegia were observed in any of the patients. Nine patients (36%) had severe arm claudication (ischemic pain within 60 seconds of beginning arm exercise and decrease of PSV between 50% and 60%). Risk factors for the condition were left vertebral artery diameter <3 mm (P < .0001). A significant correlation was found between the degree of PSV reduction and left arm symptoms (P < .0001). There was an improvement in ischemic arm symptoms (P < .0001) during mean follow-up of 36 months (range, 6-65 months), with only one patient (4.2%) presenting with severe claudication. Freedom from reintervention at 48 months was 93.5%. No signs of endoleaks or graft migrations were detected on computerized tomographic angiography control scans. CONCLUSIONS Coverage of the LSA during TEVAR for traumatic aortic injuries appears to be a feasible, safe method for extending the endograft landing zone without increasing the risk of paraplegia, stroke, or left arm ischemia. Left vertebral artery diameter can be used to identify patients at risk for postoperative left arm ischemia.

Long Term Outcomes and Sac Volume Shrinkage After Endovascular Popliteal Artery Aneurysm Repair

OBJECTIVES The aim was to evaluate long-term outcomes and sac volume shrinkage after endovascular popliteal artery aneurysm repair (EVPAR). METHODS This study was a retrospective review of all EVPAR cases between 1999 and 2012. Sac volume shrinkage, long-term patency, limb salvage, and survival were evaluated using Kaplan-Meier estimates. The association of anatomical and clinical characteristics with patency was evaluated using multivariate analysis. RESULTS Forty-six EVPAR were carried out in 42 patients (mean age 78 years, 86% male; mean sac volume 45.5 ± 3.5 mL). In 93% of cases (n = 43) the procedure was elective, while in 7% of cases it was for rupture (n = 2) or acute thrombosis (n = 1). Of the 43 patients who underwent elective repair, 58% were asymptomatic and 42% symptomatic (14 claudication, 3 rest pain, and 1 compression symptoms). Technical success was 98%. Mean duration of follow-up was 56 ± 21 months. Primary patency at 1, 3, and 5 years was 82% (SE 2), 79% (SE 4), and 76% (SE 4), while secondary patency was 90% (SE 5), 85% (SE 4), and 82% (SE 1) respectively; at 5 years there was 98% limb salvage and an 84% survival rate. During follow-up 11 limbs had stent graft failure: six required conversion, one underwent amputation, and four continued with mild claudication. Of those with graft failure, 63% (7/11) occurred within the first year of follow-up. The mean aneurysm sac volume shrinkage between preoperative and 5-year post-procedure measurement was significant (45.5 ± 3.5 mL vs. 23.0 ± 5.0 mL; p < .001). Segment coverage >20 cm was a negative predictor for patency (HR 2.76; 95% CI 0.23; p = .032). CONCLUSIONS EVPAR provides successful aneurysm exclusion with good long-term patency, excellent limb salvage, and survival rates. Close surveillance is nevertheless required, particularly during the first postoperative year. Patients requiring long segment coverage (>20 cm) may be at increased risk for failure.

Parallel Endografts in the Treatment of Distal Aortic and Common Iliac Aneurysms

OBJECTIVES Endovascular treatment of distal abdominal aortic aneurysms (D-AAA) and bilateral common iliac artery aneurysms (BCIAA) may present technical challenges for standard EVAR. Parallel iliac leg endografts (ILEs) of standard aortic devices and covered stents have been successfully employed to treat patients with D-AAA and BCIAA. The perioperative and long-term results of this straightforward endovascular technique are presented. METHODS Beginning in 2009, patients deemed unfit for open surgery underwent parallel endografts D-AAA and BCIAA exclusion. Avoiding the use of a main body, ILEs are simultaneously delivered from both femoral arteries, landing parallel into the aortic neck (parallel grafts: PG). Distal landing zones including external iliac arteries (EIAs) are reached using appropriate ILEs. A third parallel covered stent graft (Viabahn, Gore) is delivered from a left brachial approach to maintain prograde blood flow to one internal iliac artery (IIA) when needed. RESULTS Eighteen patients were successfully treated using parallel endografts, nine for BCIAA and nine for D-AAA. All D-AAA presented an irregular saccular shape, including three penetrating aortic ulcers and two pseudoaneurysms of previous aortic grafts. Prograde flow to one IIA was successfully maintained using a Viabahn graft in five patients with BCIAA. Mean aneurysm size was 50 mm in D-AAA and 43 mm in BCIAA. One patient required a perioperative ILE extension to treat a type Ib endoleak. One patient suffered a minor stroke 24 hours after the procedure. Two type II endoleaks were observed postoperatively. Five patients died of non-aneurysm related causes during follow-up. No new endoleaks, graft displacements or occlusions were observed during follow-up (median: 26 months, range 12-42 months). CONCLUSIONS Successful exclusion of D-AAA and BCIAA was achieved in high-risk patients using parallel endografts, allowing antegrade blood flow to one IIA when needed. Commercially available endografts were used in a simple and effective approach, with excellent follow-up results.

Open Repair for Ruptured Abdominal Aortic Aneurysm : Is It Possible to Predict Survival?

The aim of the study was to determine variables that could be used to predict survival in patients with ruptured abdominal aortic aneurysm (RAAA) and to assess the accuracy of the Glasgow Aneurysm Score (GAS) and the Acute Physiology Chronic Health Evaluation II (APACHE-II). From January 1998 to July 2006, 103 patients underwent operations for RAAA. For each patient, 44 variables were retrospectively recorded in a database. Data were analyzed with univariate and multivariate methods. In the univariate analysis significant predictors of death were hypotension (p=0.001), preexisting peripheral vascular disease (p<0.001), renal insufficiency (p=0.037), chronic obstructive pulmonary disease (p=0.028), level of HCO(3)(-) (p<0.001), intraperitoneal rupture (p=0.001), blood transfused (p<0.001), cardiac complications (p<0.001), and APACHE-II score (p=0.001). Multivariate analysis confirmed statistical significance for coexisting peripheral vascular disease (p<0.001), diastolic blood pressure at admission <60 mm Hg (p=0.039), APACHE-II score >18.5 (p=0.025), HCO(3)(-) <21 mg/dL (p<0.001), and intraperitoneal rupture of the aneurysm (p=0.011) as predictors of death. Results of the study suggested that different factors can be helpful in identifying those patients whose operative risk is prohibitive. APACHE-II, contrary to GAS, is an accurate system to predict postoperative death after repair for RAAA.

Transcatheter Repair of Combined Ascending Aortic Pseudoaneurysm and Aortic Arch Aneurysm Through a Cardiac Transapical Approach

We describe a new surgical technique performed in a heart-transplanted patient who underwent transcatheter repair of combined ascending aortic pseudoaneurysm and aortic arch aneurysm. The endografts were deployed through a left ventricular transapical approach by using a left mini-thoracotomy after previous debranching of the brachiocephalic vessels.