Paolo Cerini

Endovascular treatment of intracranial aneurysms with flow-diverter stents: preliminary single-centre experience

PurposeThis paper reports our preliminary experience with the endovascular treatment of intracranial aneurysms using flow-diverter stents (FDs) and compares it with the literature data.Materials and methodsFrom May 2009 to April 2012, 28 patients (6 men and 22 women; mean age, 54 years) with a total of 35 aneurysms were treated with FDs. We evaluated postprocedural technical success and long-term efficacy, with follow-up examinations performed at 3–7 days [computed tomography (CT)/magnetic resonance (MR) angiography] and at 3, 6 and 12 months (digital subtraction angiography, DSA). A total of 43 FDs were placed, 36 Pipeline and 7 Silk.ResultsA total of 30 procedures were performed (two patients were treated twice). Technical success was 96.6%, with one case of postprocedural death; the aneurysm exclusion rate at 3, 6 and 12 months was 60%, 73% and 89%, respectively. There was no case of acute stent thrombosis, and only two cases of nonsignificant stenosis. All covered side branches were patent, except one case of steno-occlusion of the ophthalmic artery.ConclusionsOur results are consistent with the literature and demonstrate the effectiveness and safety of FDs in selected cases of cerebral aneurysm (wide neck, fusiform, blister-like).RiassuntoObiettivoScopo del presente lavoro è riportare la nostra esperienza nel trattamento endovascolare degli aneurismi cerebrali mediante stent a diversione di flusso (FD), confrontandola con i dati della letteratura.Materiali e metodiDa maggio 2009 ad aprile 2012 sono stati trattati mediante FD 28 pazienti (6 maschi e 22 femmine; età media 54 anni) portatori di 35 aneurismi cerebrali. Abbiamo valutato il successo tecnico procedurale e l’efficacia a distanza mediante angiotomografia computerizzata (TC) o angio-risonanza magnetica (RM) a 3–7 giorni, quindi angiografia digitale a sottrazione (DSA) a 3, 6 e 12 mesi. Sono stati posizionati complessivamente 43 FD, 36 Pipeline e 7 Silk.RisultatiComplessivamente sono stati eseguiti 30 interventi (due ritrattamenti a 3 mesi per copertura parziale del colletto aneurismatico). Abbiamo ottenuto il successo tecnico nel 96,6% dei casi, con un caso (3,4%) di insuccesso esitato in decesso post-operatorio. L’esclusione dal circolo dell’aneurisma è stata a 3, 6 e 12 mesi rispettivamente del 60%, 73% ed 89%. Non abbiamo osservato nessun caso di trombosi intra-stent, solo due casi di stenosi lieve intra-stent, risoltesi poi al followup; in tutti i casi i vasi collaterali ricoperti dagli stent sono risultati pervi, eccetto un caso di steno-occlusione dell’arteria oftalmica.ConclusioniI risultati da noi ottenuti, in linea con i dati della letteratura, documentano che il trattamento degli aneurismi cerebrali mediante FD rappresenta un’opzione sicura ed efficace in casi selezionati (aneurismi a largo colletto, fusiformi, blister-like), con buoni risultati nel tempo.

Long-term efficacy of endovascular treatment of isolated iliac artery aneurysms

PurposeThe aim of this study was to evaluate the efficacy of endovascular treatment of isolated iliac artery aneurysms (IIAA) and compare our data with those reported in the literature.Materials and methodsFrom May 2005 to December 2010, 32 patients (31 men and one woman; mean age 73±12 years) with a total of 40 IIAAs underwent endovascular treatment at our institute. We evaluated technical success, long-term patency, early and late complications and overall mortality.ResultsAt a median follow-up of 36 months, we achieved a technical success of 100%, a primary patency of 95% and a secondary patency of 100%, with complete exclusion of the aneurysm in 84.6% of cases. In 12.8% of cases, there was a reduction in aneurysm sac volume, with an incidence of type II endoleak of 12.8%. Overall survival at 1, 2, 3, and 6 years was 96.8%, 84.2%, 66.6% and 64%, respectively.ConclusionsOur study documents the effectiveness of endovascular treatment of iliac aneurysms, which has become the first-choice treatment at our institute. This finding is consistent with the most recent literature and confirms the safety and long-term patency of stent-graft placement.RiassuntoObiettivoScopo del presente lavoro è stato valutare l’efficacia del trattamento endovascolare degli aneurismi isolati dell’asse arterioso iliaco (IIAA) e confrontare i nostri dati con quelli della letteratura.Materiali e metodiDa maggio 2005 a dicembre 2010, 32 pazienti (31 maschi ed 1 femmina; età media 73±12 anni) con un totale di 40 IIAA sono stati sottoposti a trattamento endovascolare. Sono stati valutati il successo tecnico, la pervietà a distanza, le complicanze precoci e tardive e la mortalità complessiva.RisultatiAd un follow-up medio di 36 mesi, abbiamo ottenuto successo tecnico del 100%; pervietà primaria del 95% e pervietà secondaria del 100%; esclusione dal circolo dell’aneurisma dell’84,6%. Nel 12,8% dei casi si è osservata riduzione volumetrica della sacca aneurismatica con incidenza di endoleak di II tipo del 12,8%. La sopravvivenza complessiva ad 1, 2, 3, e 6 anni è stata del 96,8%, 84,2%, 66,6%, 64% rispettivamente.ConclusioniIl nostro studio documenta l’efficacia del trattamento endovascolare degli aneurismi iliaci, che è diventata l’opzione di prima scelta nel nostro istituto. Tale riscontro è in linea con i più recenti dati della letteratura e conferma la sicurezza e la validità a lungo termine del posizionamento di endoprotesi.

Endovascular treatment of bronchial artery aneurysm with aortic stent-graft placement and coil embolization.

Bronchial artery aneurysm (BAA) represents a rare, but dangerous, pathology because its rupture can cause a life-threatening hemorrhage; opportune treatment is mandatory when a definite diagnosis is obtained. There are several reports of endovascular treatment of BAA with transcatheter arterial embolization and only few cases treated with aortic stent-graft exclusion. We report a case of mediastinal BAA close to thoracic aorta treated with a combined approach of stent-graft occlusion of the inflow and coil embolization of the outflow arteries.

Endovascular treatment of popliteal artery aneurysms: preliminary results.

PurposePopliteal artery aneurysms (PAAs) are a rare condition with an incidence <0.1%. The objective of this study was to evaluate the effectiveness of endovascular treatment of PAA with a covered stent-graft.Materials and methodsBetween January 2009 and July 2010, ten patients (nine men and one woman, mean age 69±12 years) with PAA were treated by endovascular placement of a heparin-coated stent-graft. All procedures were evaluated in terms of technical success, patency at 1, 6 and 12 months as assessed by colour Doppler ultrasound, complications, procedure duration and length of postoperative hospital stay.ResultsWe obtained 100% technical success, with no peri- or postprocedural complications. Average duration of the procedure was 40 min, and mean hospital stay was 3 days. Primary and secondary patency rates at 1, 6 and 12 months were 100% and 100%, 90% and 100%, and 90% and 100%, respectively. Only one case of endoleak occurred.DiscussionIn keeping with the literature, our study demonstrates the effectiveness of endovascular repair of PAA, with short- and mid-term patency rates comparable to those of open surgery. Larger series and longer follow-up periods are needed to confirm these preliminary results.RiassuntoObiettivoGli aneurismi dell’arteria poplitea (PAA) sono un patologia rara, con incidenza <0,1%. Obiettivo del nostro studio è valutare l’efficacia del trattamento endovascolare degli PAA mediante stent ricoperto.Materiali e metodiDa gennaio 2009 a luglio 2010, 10 pazienti (9 maschi e 1 femmina; età media 69±12 anni) affetti da PAA sono stati sottoposti a trattamento endovascolare mediante posizionamento di stent ricoperto eparinato. Sono stati valutati il successo tecnico procedurale, la pervietà a 1, 6 e 12 mesi mediante ecocolor Doppler, le complicanze associate, la durata della procedura e la degenza post-operatoria.RisultatiAbbiamo ottenuto il 100% di successo tecnico, in assenza di complicanze peri- e post-procedurali. La durata media della procedura è stata di 40 minuti con degenza ospedaliera media di 3 giorni. La pervietà primaria e secondaria a 1, 6 e 12 mesi è stata rispettivamente del 100% e 100%, 90% e 100%, 90% e 100%. è stato osservato un solo caso di endoleak.DiscussioneIl nostro studio, in linea i dati di letteratura, documenta l’efficacia del trattamento endovascolare degli PAA, con pervietà nel breve e medio termine sovrapponibile all’intervento chirurgico. Sono necessari studi con maggiore casistica e più lungo follow-up per confermare questi risultati.

Management of Postbiopsy Arteriovenous Fistulas in Transplanted Kidneys and Effectiveness of Endovascular Treatment: A Single-center Experience

BACKGROUND We sought to evaluate the best therapeutic management of postbiopsy arteriovenous fistulas (AVFs) in transplanted kidneys. METHODS Between January 2005 and December 2011, we observed 17 cases of postbiopsy AVF in transplanted kidneys (9 asymptomatic; 8 symptomatic). Asymptomatic cases were managed conservatively, while patients with symptomatic AVF underwent endovascular treatment. We used a technique that consisted in a superselective transcatheter embolization of the afferent branch. We evaluated the technical success (postoperative closure of AVF), the immediate clinical efficacy (cessation of symptoms), and clinical efficacy at follow-up (measurement of serum creatinine at 7 days and 6 and 12 months compared with preoperative levels using t-tests). RESULTS Asymptomatic AVFs resolved spontaneously, while the endovascular treatment in symptomatic AVFs showed a complete technical and clinical success with prompt remission of the presented symptoms. We observed a statistically significant reduction in serum creatinine at 7 days and 6 and 12 months postoperatively (mean creatinine--preoperative: 3.23 ± 1.4 mg/dL; 7 days: 2.25 ± 0.8 mg/dL; 6 months: 1.65 ± 0.28 mg/dL; 12 months: 1.4 ± 0.26 mg/dL; in all cases P < 0.05). CONCLUSIONS In our experience, asymptomatic AVFs could be managed conservatively with close follow-up while the endovascular treatment for symptomatic AVFs is both safe and effective in the short- and long-term.

Endovascular treatment of transplanted renal artery stenosis with PTA/stenting

PurposeWe evaluated the effectiveness of endovascular treatment with percutaneous transluminal balloon angioplasty (PTA)/stenting of transplanted renal artery stenosis (TRAS).Materials and methodsBetween January 2005 and December 2010, 17 patients (4 women, 13 men; mean age 60.9 years) with TRAS underwent PTA/stenting. The parameters analysed were: technical success, pre- and post-treatment serum creatinine (SCr) and blood pressure (BP), average number of antihypertensive drugs administered before and after treatment and vessel patency on colour Doppler ultrasound (CDUS) at 1, 3, 6 and 12 months and once a year thereafter.ResultsTechnical success was 100%. During a mean follow-up of 28.3±18.7 months, there was a statistically significant reduction in SCr and BP values. In 18 % of cases, moderate (<60%) restenosis was observed on CDUS without renal failure and not requiring new treatment. There was a reduction in antihypertensive drugs from an average of 3.5±0.5 to 1.5±0.5.ConclusionsConsistent with the literature data, our experience shows that endovascular treatment with PTA/stenting is a safe and effective option for managing TRAS and can thus be considered the method of choice.RiassuntoObiettivoScopo del nostro lavoro è stato valutare l’efficacia del trattamento endovascolare mediante angioplastica percutanea transluminale (PTA)/stenting delle stenosi dell’arteria renale trapiantata (TRAS).Materiali e metodiDa gennaio 2005 a dicembre 2010, 17 pazienti (4 femmine e 13 maschi; età media 60,9 anni) affetti da TRAS sono stati sottoposti a PTA/stenting. È stato valutato il successo tecnico della procedura e sono stati confrontati i valori di creatininemia e di pressione arteriosa, il numero di farmaci anti-ipertensivi somministrati prima e dopo il trattamento e la pervietà del vaso trattato mediante eco-color Doppler (ECD) a 1, 3, 6, 12 mesi e successivamente una volta l’anno.RisultatiIl successo tecnico è stato del 100%; ad un followup medio di 28,3±18,7 mesi, si è osservata una riduzione statisticamente significativa dei valori di creatinina sierica e di pressione arteriosa. All’ECD nel 18% dei casi si è riscontrata re-stenosi di grado moderato (<60%), non associata ad alterazioni della funzionalità d’organo e non meritevole di nuovo trattamento. Si è passati da una assunzione di 3,5±0,5 farmaci anti-ipertensivi a 1,5±0,5.ConclusioniNella nostra esperienza, in linea con i dati della letteratura, il trattamento endovascolare mediante PTA/stenting rappresenta una opzione sicura ed efficace nella gestione delle TRAS, costituendo la prima scelta terapeutica.

Endovascular Treatment of Thoracic Aortic Aneurysm: A Single-Center Experience

BACKGROUND We assess the effectiveness of thoracic endovascular aortic repair (TEVAR) in patients with thoracic artery aneurysm with a retrospective analysis of our experience and a review of the literature. METHODS Between January 2005 and December 2011, 53 patients with thoracic aortic aneurysm underwent TEVAR. We evaluated the technical success, periprocedural and long-term mortality and morbidity, and follow-up by enhanced computed tomographic scans at 1, 6, and 12 months and annually thereafter. RESULTS TEVAR was performed in good general conditions in 62.3% of cases and in emergency conditions in 37.7% of cases. A total of 85 endoprostheses were correctly placed, with technical success of 100%. In 18.8% of cases, a carotid-subclavian bypass was performed; 35.8% of cases required drainage of cerebrospinal fluid. Postoperative mortality was 7.5%, and in all cases patients were treated in emergency regimen. The incidence of major postoperative complications was 9.4%, with 2 cases of paraplegia. At a mean follow-up of 25.6 months, 12 cases (22.6%) of endoleak were observed: 5 cases of type IB endoleak were treated with prosthetic extensions; 7 cases of type II endoleak were not treated. There were no thrombotic occlusions, stent migrations, or fractures. CONCLUSION TEVAR represents an effective option in the treatment of thoracic aortic aneurysms, with good immediate and long-term results.

Endovascular treatment of abdominal aortic aneurysms: 6 years of experience at a single centre

PurposeWe sought to assess the effectiveness of endovascular abdominal aortic aneurysm (AAA) repair (EVAR) through a retrospective review of 6 years’ experience at a single centre.Materials and methodsFrom April 2005 to August 2011, 222 patients affected by abdominal aortic aneurysms underwent EVAR. We evaluated primary technical success, postprocedural mortality, intraprocedural and postprocedural complications with contrast-enhanced computed tomography (CT) and contrast-enhanced ultrasound (US) follow-up at 1, 6 and 12 months and annually thereafter.ResultsThe procedures were elective in 75.7% and urgent due to symptomatic or ruptured aneurysm in 24.3%. Technical success was 98.6%; three patients (1.4%) required conversion to open surgery. Postoperative mortality rate was 24% for urgent and 2.3% for elective procedures. During a mean follow-up period of 29.6 months, no cases of stent-graft migration were observed; the overall incidence of endoleaks was 27% (60/222) and comprised four type I (1.8%) and one type III (0.45%), all treated by stent-graft extension, and 55 type 2 (24.8%), eight of which (14.5%) were treated by percutaneous injection of thrombin. In 10/222 cases (4.5%), thrombotic occlusion of the iliac extension was detected, which was successfully treated by transcatheter intra-arterial thrombolysis. One patient developed stent-graft infection requiring surgical explantation. Average hospital stay was 4 days, and average time in intensive care was 2 days.ConclusionsConsistent with the literature data, our study confirms the safety and long-term efficacy of EVAR for treating AAA.RiassuntoObiettivoValutare l’efficacia del trattamento endovascolare degli aneurismi dell’aorta addominale (EVAR) mediante una valutazione retrospettiva monocentrica della nostra esperienza di 6 anni.Materiali e metodiDa aprile 2005 ad agosto 2011, 222 pazienti affetti da aneurisma dell’aorta addominale sono stati sottoposti a EVAR. Sono stati valutati il successo tecnico primario, la mortalità postoperatoria e a distanza, le complicanze intraprocedurali e postprocedurali mediante follow-up con angio-TC ed ecografia con mdc a 1, 6 e 12 mesi e poi annualmente.RisultatiGli interventi sono stati eseguiti in elezione nel 75,7% dei casi e in urgenza nel 24,3% per aneurisma sintomatico o rotto. Il successo tecnico si è ottenuto in 219 pazienti (98,6%); in 3 pazienti (1,4%) è stata necessaria la conversione chirurgica. La mortalità postoperatoria in elezione è stata del 2,3% (4/168) mentre in regime d’urgenza del 24% (13/54). A un follow-up medio di 29,6 mesi, l’incidenza complessiva di endoleak è stata del 27% (60/222): quattro endoleak di tipo I (1,8%) e uno di tipo III (0,45%), trattati mediante stent-graft, e 55 endoleak di tipo II (24,8%), di cui 8 trattati mediante iniezione translombare di trombina. In 10/222 casi (4,5%) si è riscontrata occlusione trombotica dell’estensione iliaca, trattata mediante trombolisi intrarteriosa. Si è riscontato un caso di infezione della protesi che ne ha richiesto l’espianto. La degenza ospedaliera media è stata di 4 giorni e il tempo medio in terapia intensiva di 2 giorni.ConclusioniIl nostro studio, in linea con i dati di letteratura, documenta la sicurezza e l’efficacia a lungo termine dell’EVAR.

Trattamento endovascolare di aneurismi dell’aorta addominale: esperienza monocentrica di sei anni

PurposeWe sought to assess the effectiveness of endovascular abdominal aortic aneurysm (AAA) repair (EVAR) through a retrospective review of 6 years’ experience at a single centre.Materials and methodsFrom April 2005 to August 2011, 222 patients affected by abdominal aortic aneurysms underwent EVAR. We evaluated primary technical success, postprocedural mortality, intraprocedural and postprocedural complications with contrast-enhanced computed tomography (CT) and contrast-enhanced ultrasound (US) follow-up at 1, 6 and 12 months and annually thereafter.ResultsThe procedures were elective in 75.7% and urgent due to symptomatic or ruptured aneurysm in 24.3%. Technical success was 98.6%; three patients (1.4%) required conversion to open surgery. Postoperative mortality rate was 24% for urgent and 2.3% for elective procedures. During a mean follow-up period of 29.6 months, no cases of stent-graft migration were observed; the overall incidence of endoleaks was 27% (60/222) and comprised four type I (1.8%) and one type III (0.45%), all treated by stent-graft extension, and 55 type 2 (24.8%), eight of which (14.5%) were treated by percutaneous injection of thrombin. In 10/222 cases (4.5%), thrombotic occlusion of the iliac extension was detected, which was successfully treated by transcatheter intra-arterial thrombolysis. One patient developed stent-graft infection requiring surgical explantation. Average hospital stay was 4 days, and average time in intensive care was 2 days.ConclusionsConsistent with the literature data, our study confirms the safety and long-term efficacy of EVAR for treating AAA.RiassuntoObiettivoValutare l’efficacia del trattamento endovascolare degli aneurismi dell’aorta addominale (EVAR) mediante una valutazione retrospettiva monocentrica della nostra esperienza di 6 anni.Materiali e metodiDa aprile 2005 ad agosto 2011, 222 pazienti affetti da aneurisma dell’aorta addominale sono stati sottoposti a EVAR. Sono stati valutati il successo tecnico primario, la mortalità postoperatoria e a distanza, le complicanze intraprocedurali e postprocedurali mediante follow-up con angio-TC ed ecografia con mdc a 1, 6 e 12 mesi e poi annualmente.RisultatiGli interventi sono stati eseguiti in elezione nel 75,7% dei casi e in urgenza nel 24,3% per aneurisma sintomatico o rotto. Il successo tecnico si è ottenuto in 219 pazienti (98,6%); in 3 pazienti (1,4%) è stata necessaria la conversione chirurgica. La mortalità postoperatoria in elezione è stata del 2,3% (4/168) mentre in regime d’urgenza del 24% (13/54). A un follow-up medio di 29,6 mesi, l’incidenza complessiva di endoleak è stata del 27% (60/222): quattro endoleak di tipo I (1,8%) e uno di tipo III (0,45%), trattati mediante stent-graft, e 55 endoleak di tipo II (24,8%), di cui 8 trattati mediante iniezione translombare di trombina. In 10/222 casi (4,5%) si è riscontrata occlusione trombotica dell’estensione iliaca, trattata mediante trombolisi intrarteriosa. Si è riscontato un caso di infezione della protesi che ne ha richiesto l’espianto. La degenza ospedaliera media è stata di 4 giorni e il tempo medio in terapia intensiva di 2 giorni.ConclusioniIl nostro studio, in linea con i dati di letteratura, documenta la sicurezza e l’efficacia a lungo termine dell’EVAR.

Endoluminal Dilation Technique to Remove Stuck Port-A-Cath: A Case Report

Port-a-cath is a type of central venous catheter (CVC) designed to allow repeated access to the venous system for parenteral delivery of medications, fluids, and nutritional solutions and for sampling venous blood. After years of use or in case of damage, CVC must be removed and eventually replaced: the recovery of the device should normally be easy, with a small surgical incision of the skin and tissues surrounding the device and pulling the catheter. Sometimes, scar tissue can develop around the device, making it resistant to removal even after application of forceful traction. We report a case of stuck port-a-cath that was extracted by using endoluminal dilatation technique.