Rita Fossaceca

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.

Comparison of cryoplasty and conventional angioplasty for treating stenotic-occlusive lesions of the femoropopliteal arteries in diabetic patients: immediate, mid-term and long-term results

PurposeThe authors compared the immediate, mid-term and long-term effectiveness of cryoplasty and conventional angioplasty for treating stenotic-occlusive lesions of the femoropopliteal arteries in diabetic patients.Materials and methodsFrom October 2006 to November 2009, 48 patients with non-insulin-dependent diabetes mellitus (DM) and an indication for percutaneous revascularisation of the femoropopliteal arteries were randomly assigned to treatment with angioplasty or cryoplasty. The following parameters were analysed and compared between the two groups: immediate technical success (residual stenosis <30%) and distal run-off as assessed on postprocedural angiography, and degree of restenosis and distal run-off at 6 and 12 months, as assessed with either colour Doppler ultrasound (CDUS) or digital subtraction angiography (DSA).ResultsTreatment with angioplasty revealed a significant superiority in procedural technical success (p=0.04), a significant reduction in the degree of restenosis at 6 months (p=0.02) and a significant increase in the distal run-off at 6 (p=0.005) and 12 (p=0.01) months.ConclusionsConventional angioplasty is more effective than cryoplasty for treating stenotic-occlusive lesions of the femoropopliteal arteries in diabetic patients and provides better immediate, mid-term and long-term results.RiassuntoObiettivoScopo del nostro lavoro è stato confrontare l’efficacia immediata e a medio e lungo termine della crioplastica e dell’angioplastica nel trattamento delle lesioni steno-ostruttive del distretto femoro-popliteo in pazienti diabetici.Materiali e metodiDa ottobre 2006 a novembre 2009, 48 pazienti affetti da diabete mellito con indicazione ad intervento di rivascolarizzazione percutanea dell’asse femoro-popliteo sono stati assegnati in maniera randomizzata al trattamento mediante crioplastica ed angioplastica. I parametri analizzati e confrontati tra i due gruppi di trattamento sono stati: successo tecnico (stenosi residua <30%) e run-off distale al termine della procedura, valutati angiograficamente, grado di restenosi e run-off distale a 6 e 12 mesi, valutati mediante eco-color Doppler o angiografia.RisultatiNel gruppo trattato con angioplastica si è riscontrato un incremento significativo di successo tecnico post-procedurale (p=0,04), una riduzione significativa del grado di restenosi a 6 mesi (p=0,02) ed un significativo incremento del run-off distale a 6 (p=0,005) e 12 mesi (p=0,01) rispetto al gruppo trattato con crioplastica.ConclusioniL’angioplastica convenzionale risulta più efficace della crioplastica nel trattamento delle lesioni steno-ostruttive del distretto femoro-popliteo in pazienti diabetici, con migliori risultati immediati ed a medio e lungo termine.

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.

MRI Post-vertebroplasty

Purpose.Percutaneous vertebroplasty (PVP), first described by Hervè Deramond in 1984, is an interventional procedure for the treatment of aggressive vertebral angioma. The aim of this study was to evaluate magnetic resonance imaging (MRI) patterns in the affected vertebrae before and after vertebroplasty by determining changes in signal intensity and size and distribution of bone cement within the vertebra at follow-up carried out at 1 week, 6 months and 12 months.Materials and methods.Fourteen patients were examined using MRI, for a total of 41 treated vertebrae; MRI was performed with a 0.5-Tesla (T) superconductive magnet (SIGNA GE).Results.MRI patterns following vertebroplasty are mainly characterised by the signal produced by the areas surrounding the cement and by the cement itself. There is little effect on the size of the treated vertebra. Acrylic cement appears as an intraspongy focal area of T1 and T2 hypointensity that is mostly oval (34%) or rounded (26.8%); this appearance tends to become stable 6 months after treatment. The area surrounding the cement appears hypointense on T1 and hyperintense on T2, a likely expression of bone marrow oedema; this signal alteration tends to disappear gradually.Conclusions.In pre- and post-vertebroplasty imaging, MRI is regarded as the reference standard for correct evaluation of both container and content. Awareness of cement changes over time and of the reaction of the surrounding bone tissue is crucial for correct assessment of post-vertebroplasty images.

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.

Emergency endovascular treatment of acute symptomatic or ruptured abdominal aortic aneurysm: a single-center experience.

The purpose of this study is to report our early experience with endovascular treatment of patients with symptomatic non-ruptured (sAAA) or ruptured (rAAA) abdominal aortic aneurysms. Between September 2005 and September 2008, all patients with a diagnosis of sAAA or rAAA were evaluated for endovascular suitability. We did not consider hemodynamic instability to be a contraindication for endovascular aneurysm repair (EVAR). Patients whose aneurysm anatomy was not suitable for EVAR received open repair (OR). A total of 46 patients with sAAA or rAAA underwent emergency EVAR: in particular, 18/46 patients were treated for sAAA and 28/46 for rAAA. Successful stent-graft deployment was achieved in 44 patients (96%); we had two open surgical conversions. The 30-day mortality rate was 19.5%. Nine patients died during the first 30 postoperative days: four patients died within 24 hours because of severe hypovolemic shock, two died of respiratory failure, one died as a result of bowel ischemia and two because of myocardial infarction after hospital discharge. Complete follow-up data were available for 35 patients (median 185 days; range 30–730 days). In conclusion, endovascular treatment is feasible and the early experience is promising. The capability of offering EVAR and OR for sAAA and rAAA according to our experience suggests that EVAR and OR should be regarded as complementary techniques to improve outcome of patients with acute AAA.