Raffaella Nice Berchiolli

Laparoscopic treatment of splenic artery aneurysms

OBJECTIVES The purpose of this study was to report a series of 16 consecutive patients who underwent laparoscopic treatment of splenic artery aneurysms. METHODS Over a period of 8 years, patients were selected for the laparoscopic option by a team of specialists that included the vascular surgeon, the interventional radiologist, and the laparoscopic surgeon. The mean size of the aneurysm was 32 mm and most was located at the splenic hilum. They were twice as common in females as in males. Ultrasonography with color Doppler function was used to define intraoperative strategy. RESULTS The laparoscopic treatment entailed excision of the aneurysm or its exclusion, usually reserved for distally located lesions. In one patient, laparoscopic resection and robotic anastomosis of the splenic artery was performed to re-establish flow to the spleen. In two patients, the intraoperative decision was added to combine a laparoscopic splenectomy due to insufficient residual arterial flow to the spleen. There was no conversion, or need for re-operation or related mortality. Analysis of intraoperative arterial flow data avoided unnecessary splenectomy following noncritical reduction of flow to the spleen. CONCLUSIONS The use of intraoperative color Doppler ultrasonography is essential in deciding the appropriate procedure and whether the spleen should be removed or saved. Early control of the splenic artery proximal to the aneurysm can limit the risk of conversion due to intraoperative bleeding. Distally located aneurysms are more difficult to manage and entail a higher risk of associated splenectomy. The laparoscopic option offers some advantages over the endovascular treatment in selected patients. A multidisciplinary approach is the key to a successful treatment of this uncommon disease.

Electromagnetic navigation platform for endovascular surgery: how to develop sensorized catheters and guidewires.

Endovascular procedures are nowadays limited by difficulties arising from the use of 2D images and are associated with dangerous X‐ray exposure and the injection of nephrotoxic contrast medium.

Outcomes of three years of teamwork on critical limb ischemia in patients with diabetes and foot lesions

To evaluate the outcomes of a multidisciplinary team working on diabetic foot (DF) patients with critical limb ischemia (CLI) in a specialized center, the authors retrospectively traced all the patients admitted in their department in 3 consecutive years with a diagnosis of CLI. From January 2006 to December 2008, 245 consecutive DF patients with CLI according the TransAtlantic interSociety Consensus II criteria were included in the study. Treatment strategy was decided by a team of diabetologists, inteventional radiologists, and vascular surgeons. Technical and clinical success, mortality, and ulcer recurrence were evaluated at 6 months and at a mean follow-up of 19.5 ± 13.4 months. Percutaneous transluminal angioplasty (PTA) was performed in 189 (77%) patients, whereas medical treatment, open surgical revascularization (OSR), and primary amputation were performed in 44 (18.3%), 11 (4.3%), and 1 (0.5%) patients, respectively. Revascularization was successful in 227/233 (97.4%) patients. At follow-up, the overall clinical success rate was 60.4%; it was significantly (P = .001) higher after revascularization (75.9%) compared with medical treatment (48.3%). During follow-up, surgical interventions in the foot were 1.5 ± 0.4 in those treated with PTA, 1.6 ± 0.5 in those treated with OSR, and 0.3 ± 0.8 in those receiving medical therapy (P < .05 compared with the others). Ulcer recurrence occurred in 29 (11.8%) patients: 4 (1.6%) in PTA, 2 (0.8%) in OSR, and 23 (9.4%) in the medical therapy group (P < .05). Major amputation rate was 9.3%, being significantly (P = .04) lower after revascularization (5.2%) compared with medical therapy alone (13.8%). Cumulative mortality rate was 10.6%. In conclusion, this study confirms the positive role of a PTA-first approach for revascularizing the complex cases of DF with CLI in a teamwork management strategy.

Simultaneous tracking of catheters and guidewires: comparison to standard fluoroscopic guidance for arterial cannulation.

OBJECTIVES The purpose of this in vitro study was to clinically assess the feasibility of a three-dimensional (3D) electromagnetic (EM) navigator, including sensorized catheters and guidewires, to determine any reduction in radiation dose and contrast medium injection. METHODS The study was performed using a navigator prototype developed at the EndoCAS center. The system includes catheters and guidewires simultaneously tracked with an EM localizer (Aurora, Northern Digital, Waterloo, Canada). Tests were performed on a commercial abdominal aortic aneurysm model. Fifteen operators were asked to cannulate renal arteries using the conventional fluoroscopic guidance and the EM navigator without fluoroscopic support. Each trial was video-recorded and analyzed for timing and success of completing the cannulation task by two blinded and independent observers. Performances were also qualitatively evaluated using the Imperial College Endovascular Cannulation Scoring Tool (IC3ST). Moreover, a questionnaire was administered to participants to evaluate the navigator potentialities. RESULTS Quantitative analysis results show no significant difference between the fluoroscopic and EM guidance regarding the total procedure time (median 2.36 minutes [interquartile range {IQR} = 1.26-4.7) vs. 2.95 min [IQR = 1.35-5.38], respectively; p = .93); number of total hits with catheter/guidewire tip to vessels wall (median 5.50 [IQR = 2.00-10.00] vs. 3.50 [IQR = 2.50-7.00], respectively; p = .65); and number of attempts at cannulation (median 4.0 [IQR = 2.00-5.00] vs. 4.0 [IQR = 2.00-5.00], respectively; p = .72]. Moreover, there was no significant difference between the IC3ST score obtained using the EM navigator and the traditional method (average 22.37 [STD = 7.95] vs. 21.58 [STD = 6.86]; p = .92). Finally, questionnaire results indicate a general agreement concerning the navigator usefulness, which clearly shows the positions of instruments inside the 3D model of the patients anatomy. Participants also agreed that the navigator can reduce the amount of contrast media delivered to the patient, as well as fluoroscopy time. CONCLUSIONS This work provides proof of concept that simultaneous EM navigation of guidewires and catheters is feasible without the use of live fluoroscopic images.

Endovascular repair of an aorto-left renal vein fistula due to a ruptured abdominal aortic aneurysm after EVAR.

Purpose: To report an unusual late complication of endovascular aneurysm repair: an arteriovenous fistula between the aneurysm sac and a retro-aortic left renal vein following sac expansion due to a type III endoleak. Case Report: A 79-year-old man developed an arteriovenous fistula between the aneurysm sac and a retro-aortic left renal vein 67 months after endovascular aneurysm exclusion (EVAR). Aneurysm rupture was due to disconnection between the right iliac limb and an extender cuff. The problem was repaired percutaneously with another endograft bridging the two prostheses. At 16 months, the aneurysm sac diameter was decreased; there was no evidence of the AV fistula, and the patient was free from any complication related to the EVAR. Conclusions: This case emphasizes the need of close surveillance even in the late postoperative course of these patients. Moreover, this rare event confirmed that endovascular techniques can play an important role in treating emergent complications.

Laparoscopic-assisted treatment of abdominal aortic aneurysm requiring suprarenal cross-clamping

OBJECTIVE Hand-assisted laparoscopic surgery (HALS) was previously employed to treat patients with infrarenal abdominal aortic aneurysm (IAAA). The use of HALS for juxtarenal abdominal aortic aneurysm (JAAA) has never been validated. In this study, we report our experience with this technique to demonstrate its feasibility and prove its safety in dealing with JAAA. METHODS From October 2000 to October 2008, we have selectively treated 271 patients with abdominal aortic aneurysm with the HALS technique. Of these, 83 were JAAAs which required a suprarenal aortic clamping (group A), and 188 were IAAA (group B). General data of the two groups were analyzed for comparability purposes and operative and postoperative data were prospectively collected. Additionally, patients in group A were stratified in three classes according to their pre-existing degree of renal function impairment. Statistical significance was defined at the P < .05 level. RESULTS Mean operative time was 220 minutes +/- 66 in group A and 231 minutes +/- 64 in group B (P > .05). The mean duration of suprarenal clamping was 28 minutes +/- 6; whereas infrarenal clamping lasted an average of 25 minutes +/- 5 (P > .05). Mean intraoperative blood loss was 1023 +/- 584 mL for group A and 961 +/- 633 mL for group B (P > .05). No conversion or 30-day postoperative mortality was recorded in either group. Sixteen percent of the patients in group A developed a postoperative complication, vs 11% in group B (P > .05). Mean postoperative stay for group A and B was 4.2 +/- 1.5 and 4.2 +/- 1.9 days, respectively (P > .05). Postoperative kidney function significantly worsened in 5 patients in group A (6%). A prolonged warm ischemia time (>40), pre-existing renal dysfunction, and diabetes, correlated to the development of postoperative renal insufficiency. Follow-up of patients averaged 37.9 +/- 20 months. The incidence of incisional hernias in group A and B was 15.5% vs 11.1%, respectively (P > .05). CONCLUSION The HALS technique proved to be feasible and safe not only for patients with IAAA, but also for the management of patients with JAAA. No significant difference could be shown in the comparison between the two groups, apart from the expected higher rate of postoperative renal dysfunction after suprarenal clamping. In view of the demonstrated benefit of this minimally invasive approach, we believe that it should be included among the alternative options of treatment for these patients.

Renal hypertension due to giant perirenal haematoma: permanent resolution by percutaneous ultrasound-guided drainage.

We describe a case of renovascular hypertension accompanied by renal failure, arising in a young man with a solitary kidney 4 months after a blunt abdominal trauma. A giant haematoma was found around the right kidney and ultrasound-guided percutaneous drainage completely relieved the symptom complex. Nine years later, the patient is normotensive with normal renal function.

Transcutaneous Oxygen and Carbon Dioxide Measurement in Peripheral Vascular Disease

Combined transcutaneous oxygen tension (tcPO2) and transcutaneous carbon dioxide tension (tcPCo2) measurements were carried out at both the subclavicular and metatarsal level in 29 controls and 100 patients with peripheral arterial obstructive disease (PAOD) (intermittent claudication: n = 40, critical limb ischemia: n = 60). Interindividual variation coefficients of arterial and subclavicular tcPCO2 (n = 94 subjects) were superimposable, while tcPo2 variability was twice the arterial value. Furthermore, arterial tensions were better predicted by tcPCO2 than by tcPO2 measurement. In the 75 limbs with an ABI < 0.9 of patients with intermittent claudication, tcPCO2 did not differ significantly from controls (n = 58 limbs), but it was elevated in those with critical limb ischemia (n = 74 limbs), although control and pathological values overlapped widely even in this latter group. At variance with tcPCO2, tcPQ2 was lower in intermittent claudication than in controls, and undetectable in most of the symptomatic limbs with critical ischemia, irrespective of concomitant diabetes. In the overall sample (n = 255 limbs), tcPCO2 did not show significant changes for tcPo2 values ranging from 80 to 10 mmHg, and it increased markedly in several—but not all—patients whose tcPo2 values were below that limit. To evaluate further the biological significance of an increase in tissue tcPCO2, another sample of 24 subjects underwent acute forearm ischemia for a period of thirteen minutes, a maneuver that increased tcPCO2 markedly, indicating that this parameter is indeed a correlate of drastic reductions in limb perfusion. Thus, tcPCO2 is methodologically less variable than tcPo2 and more predictive of arterial values. However, the wide overlap with control values restrains its use as an isolated diagnostic tool to substantiate PAOD, even in the most advanced stages of disease. Marked elevations in tCPCO2 can be found in patients with critical limb ischemia, although normal values may coexist with low or negligible tcPO2 levels for reasons to be clarified. Further work is needed to establish the extent to which tcPcO2 determination may complement tcPO2 to differentiate extreme from less severe degrees of critical limb ischemia.

PET/MRI in Infection and Inflammation

Hybrid positron emission tomography/magnetic resonance imaging (PET/MR) systems are now more and more available for clinical use. PET/MR combines the unique features of MR including excellent soft tissue contrast, diffusion-weighted imaging, dynamic contrast-enhanced imaging, fMRI and other specialized sequences as well as MR spectroscopy with the quantitative physiologic information that is provided by PET. Most of the evidence of the potential clinical utility of PET/MRI is available for neuroimaging. Other areas, where PET/MR can play a larger role include head and neck, upper abdominal, and pelvic tumours. Although the role of PET/MR in infection and inflammation of the cardiovascular system and in musculoskeletal applications are promising, these areas of clinical investigation are still in the early phase and it may be a little longer before these areas reach their full potential in clinical practice. In this review, we outline the potential of hybrid PET/MR for imaging infection and inflammation. A background to the main radiopharmaceuticals and some technical considerations are also included.

Preliminary results of endovascular aneurysm sealing from the multicenter Italian Research on Nellix Endoprosthesis (IRENE) study

Objective: Because of advances in technology and experience of the operator, endovascular aneurysm repair (EVAR) has supplanted open repair to treat abdominal aortic aneurysm (AAA). The low 30‐day mortality and morbidity of EVAR make the endovascular approach particularly suitable for patients at high surgical risk. However, endoleak or endograft migration requiring secondary intervention or open surgical conversion is a limitation of EVAR. The Nellix system (Endologix, Inc, Irvine, Calif) has been designed to seal the entire AAA to overcome these limitations with EVAR. We report the results of a retrospective, multicenter study with endovascular aneurysm sealing (EVAS) aimed to assess technical success, procedure‐related mortality, complications, and reinterventions. Methods: This study included patients selected for elective treatment with the Nellix device per the endovascular repair protocol at 16 Italian vascular centers. All patients were enrolled in a postoperative surveillance imaging program including duplex ultrasound investigations, computed tomography, and magnetic resonance controls following local standards of care. Results: From 2013 to 2015, there were 335 patients (age, 75.5 ± 7.4 years; 316 men) who underwent elective EVAS. In 295 cases (88.0%), EVAS was performed under standard instructions for use of the Nellix system. Preoperative aneurysm diameter was 55.5 ± 9.4 mm (range, 46‐65 mm). The inferior mesenteric artery and lumbar arteries emerging from the AAA were patent in 61.8% and 81.3% of cases, respectively. Chimney grafts were electively carried out in eight cases (2.4%). One (0.3%) intraprocedural type IB endoleak was observed and promptly corrected. Device deployment was successful in all patients, with no perioperative mortality. Early (≤30 days) complications included 1 (0.3%) type IA endoleak, 2 (0.6%) type II endoleaks (0.6%), 2 (0.6%) stent occlusions (0.6%), 3 (0.9%) distal embolizations, and 2 (0.2%) femoral artery dissections. Six (2.9%) patients underwent reinterventions. At 1‐year follow‐up, complications included 3 (1.1%) type II endoleaks, 4 (1.4%) type IA endoleaks, 1 (0.3%) type IB endoleak, 2 (0.7%) distal stent migrations, 5 (1.8%) distal embolizations, and 1 (0.3%) stent occlusion. Twelve patients (3.7%) underwent reinterventions, including four (1.4%) surgical conversions due to aortoduodenal fistula (1), endograft infection (1), and type IA endoleak that was unsuccessfully treated percutaneously (2). Two AAA‐related deaths occurred. Freedom from aneurysm‐related reintervention was 98.3% at 1‐month and 94.7% at 12‐month follow‐up. Conclusions: The preliminary results of this real‐world multicenter study showed that EVAS with Nellix for the management of AAAs appears feasible. This device platform is associated with acceptable procedure‐related mortality and low overall complication and reintervention rates. Definitive conclusions on the value of this novel device await long‐term follow‐up data.