Stylianos Koutsias

Outcome after endovascular stent graft repair of aortoenteric fistula: A systematic review

BACKGROUND Aortoenteric fistula (AEF) is a critical clinical condition, which may present with gastrointestinal hemorrhage, with or without signs of sepsis. Conventional open surgical repair is associated with high morbidity and mortality. Endovascular stent graft repair has been attempted, but recurrent infection remains of major concern. We conducted a systematic review to assess potential factors associated with poor outcome after endovascular treatment. METHODS The English literature was searched using the MEDLINE electronic database up to April 2008. All studies reporting on the primary management of primary or secondary AEF with endovascular stent graft repair were considered. RESULTS Data were extracted from 33 reports that included 41 patients and were entered in the final analysis. Persistent/recurrent/new infection or recurrent hemorrhage developed in 44% of the patients, after a mean follow-up period of 13 months (range, 0.13-36). Secondary, as compared to primary, AEF had an almost threefold increased risk of persistent/recurrent infection. Evidence of sepsis preoperatively was found to be a factor indicating unfavorable outcome (P < .05). Persistent/recurrent/new infection after treatment was associated with worse 30-day and overall survival compared with those who did not develop sepsis (P < .05). CONCLUSION Endovascular stent graft repair of AEF was associated with a high incidence of infection or recurrent bleeding postoperatively. Evidence of sepsis preoperatively was indicating poor outcome.

Endovascular Stent-Graft Repair of Major Abdominal Arteriovenous Fistula: A Systematic Review

Purpose: To evaluate the outcomes of endovascular stent-graft repair of major abdominal arteriovenous fistulas. Methods: The English literature was systematically searched using the MEDLINE electronic database up to January 2009. All reports on endovascular stent-graft repair of major abdominal arteriovenous fistula were considered. Our experience of abdominal arteriovenous fistula was involved in the data analysis. The primary outcome measures were technical success and perioperative, 30-day, and overall mortality. Results: Data for the final analysis were extracted from 21 papers reporting on 22 patients and from the medical records of a patient treated at our institution. The most common causal associations of these fistulae were the presence of an aortoiliac aneurysm and previous endovascular aneurysm repair, accounting for 56% and 13% of all associations, respectively. The technical success rate was 96% (22/23). No perioperative or 30-day mortality was noticed during a mean follow-up of 9 months. The most common procedure-related complication was type II endoleak, which was found in 22% (5/23) of the patients. This event was either self limiting or required minimal percutaneous intervention. Conclusion: Endovascular stent-graft repair of major abdominal arteriovenous fistula is a safe and effective treatment option, with good short- and midterm results. However, no long-term data exist, and larger series are required to draw solid conclusions regarding the outcomes of this method.

Hybrid Endovascular and Open Treatment of Severe Multilevel Lower Extremity Arterial Disease

OBJECTIVE To evaluate the feasibility and efficacy of simultaneous combined endovascular and open lower extremity arterial reconstruction. DESIGN Case series study with retrospective analysis of prospectively collected non-randomised data. METHODS Patients were divided into three groups: group 1 and group 2 included patients who underwent endovascular reconstruction proximal and distal to the site of open reconstruction, respectively, whereas group 3 included patients who underwent open surgery with both proximal and distal endoluminal procedures. Patency analyses were performed using Kaplan-Meier life tables. Univariate and multivariate analyses were used to assess the influence of various risk factors on primary patency. RESULTS Complete data were obtained from 60 patients who underwent 61 single-step hybrid procedures. Technical and haemodynamic success rates were 100% and 95%, respectively. The perioperative mortality rate was 3%. The primary and assisted-primary patency rates at 12 months were 71% and 98%, respectively. Primary patency rates were lower in group 3 when compared with groups 1 and 2 (log-rank test, p=0.006). The presence of diabetes and dyslipidaemia were independent predictors of decreased primary patency (p=0.003 and p=0.014, respectively). CONCLUSIONS Hybrid procedures provide an effective treatment management of selected patients with multilevel lower extremity arterial disease. The extent of the disease, diabetes and dyslipidaemia are associated with worse outcome.

Peripheral Arterial Disease Is Prevalent But Underdiagnosed and Undertreated in the Primary Care Setting in Central Greece

We investigated the prevalence of peripheral arterial disease (PAD). Primary Care Health Centers (n = 14) in Thessaly (central Greece) recruited 436 participants, mean age 71 (50-79) years. Peripheral arterial disease was considered present if the ankle–brachial index (ABI) was <0.9 or >1.4 in at least 1 leg. Asymptomatic PAD was defined as an abnormal ABI and no symptoms or history of limb revascularization. The prevalence of PAD was 13% (mostly asymptomatic, 11.7%). Only 5 (8.77%) of 57 patients with PAD were aware of their disease and only in these patients were the physicians aware of the presence of PAD. The risk factors associated with PAD were age, smoking, and the combination of diabetes mellitus and coronary artery disease. All symptomatic patients were on antiplatelet therapy but 33% did not take statins. For asymptomatic patients, 74.5% were not on antiplatelet therapy and 57% did not receive statins. In the primary health care setting, PAD is underdiagnosed and undertreated.

The ovation abdominal stent graft for the treatment of abdominal aortic aneurysms: current evidence and future perspectives

ABSTRACT The Ovation Abdominal Stent Graft System is a trimodular endoprosthesis recently introduced for the endovascular repair of abdominal aortic aneurysm (AAA). It uncouples the stages of stent-graft fixation and sealing with the suprarenal fixation achieved with a long, rigid anchored stent while the sealing onto the neck is accomplished via a pair of polymer-filled inflatable rings that accommodate to each patient’s individual anatomy. Moreover, the lack of Nitinol support enables lower profiles of the endograft’s delivery system, thus facilitating the navigation through angulated and stenosed iliac vessels. Ovation’s novel design expands further the AAA eligibility to endovascular repair. This article discusses the clinical and hemodynamic consequences of the Ovation design and contributes to better understanding of current and future implications.

Remote endarterectomy for long segment superficial femoral artery occlusive disease. A systematic review.

BACKGROUND Remote endarterectomy is a minimally invasive procedure which combines open and endovascular surgery for the treatment of long segment superficial femoral artery (SFA) occlusive disease. We conducted a systematic review of the medical literature to analyze the indications, technical limitations and the outcome of remote SFA endarterectomy (RSFAE). METHODS The English literature was searched using the MEDLINE electronic database up to February 2008. We considered studies comprising at least 10 patients treated with RSFAE and reporting on the primary and/or secondary patency rates. Average primary and secondary patency rates were obtained by weighting the data of each study by the number of limbs treated. RESULTS Our search identified 19 retrospective or prospective case series; no randomized controlled trials comparing RSFAE with another treatment modality were identified. The average technical success rate was 94% and the procedure-related complication rate was 14.7%. The weighted mean cumulative primary patency rates were 60%, 57% and 35% at 1, 2 and 5 years, respectively. The weighted mean assisted primary patency rates were 75%, 77% and 50% at 1, 2 and 5 years, respectively. The weighted mean secondary patency rates were 88% and 62% at 1 and 2 years, respectively. CONCLUSIONS RSFAE has acceptable short-, medium- and long-term results but patients should undergo intensive surveillance postoperatively. Randomized controlled trials are needed to assess the durability of this procedure as compared to conventional open bypass surgery.

Cholesterol crystal embolization: a possible complication of peripheral endovascular interventions.

Cholesterol crystal embolization (CCE) is a possible complication of peripheral endovascular interventions. The diagnosis of CCE is suggested by the gradual onset of peripheral cutaneous manifestations (e.g., livedo reticularis, blue toe syndrome) accompanied by progressive increases in blood urea nitrogen and creatinine levels following an invasive arterial procedure. On occasion, it may present with non-specific clinical signs and symptoms, which contributes to underdiagnosis. CCE is associated with significant morbidity and mortality. Prompt recognition of the presenting signs and symptoms, as well as a combination of treatment modalities is essential to reduce the risk of morbidity and mortality. CCE should always be part of the differential diagnosis in patients with progressively deteriorating renal function following a peripheral endovascular intervention. After the presentation of CCE, avoidance of anticoagulation and further invasive vascular procedures (e.g., angiography), along with symptomatic and supportive therapeutic measures, may help to achieve a better outcome.

The Role of Oral Vitamin K Antagonists in the Outcome of Infrainguinal Bypass Procedures

We investigated the role of oral vitamin K antagonists (VKAs) in graft patency, limb salvage, major and minor bleeding rates in patients undergoing infrainguinal bypass surgery. Five randomized-controlled trials (RCTs; n = 3746 patients) comparing VKA versus non-VKA treatment outcomes in patients undergoing infrainguinal bypass surgery were analyzed. The VKA treatment was associated with improved graft patency rates when a vein graft was used (risk ratio [RR]: 0.74; P = .0004), while there was no difference with prosthetic grafts (RR: 1.07; P = .39). The VKA treatment was also associated with improved limb salvage rates (RR: 0.33; P = .0008). Major and minor bleeding complications were higher in the VKA group. In conclusion, VKA treatment is associated with improved graft patency and limb salvage rates when a vein graft is used at the price of an increased risk of bleeding. Due to the inconsistent results, further well-designed RCTs are needed.

Colonic Ischemia After Endovascular Exclusion of an Aortoiliac Aneurysm Using an Iliac Branch Device

Purpose: To present the first case of colonic ischemia (CI) after endovascular exclusion of an aortoiliac aneurysm using an iliac branch device (IBD). Case report: A 69-year-old male patient with an abdominal aortic and right common iliac artery aneurysm underwent endovascular repair with an IBD. Completion angiography demonstrated good patency in 2 of the 3 main branches of the right internal iliac artery (IIA) whereas the left IIA patency was preserved. Preoperatively, the inferior mesenteric artery (IMA) was patent. Postoperatively, the patient presented moderate CI. He was treated conservatively and discharged 15 days later with recession of the symptoms. Conclusion: Although preservation of bilateral iliac artery patency is considered to diminish the incidence of pelvic ischemia, in case of an exclusion of a patent IMA, collaterals may not be adequate to ensure blood supply to the left colon.

Development of an mHealth Open Source Platform for Diabetic Foot Ulcers Tele-consultations

Diabetes is one of the foremost causes of death in many countries and a leading cause of blindness, renal failure, and non-traumatic amputation. Therefore, diabetic foot ulceration and amputation cause extensive burden on individuals and health care systems in developed and developing countries. Due to the multi-disciplinary requirements for the treatment of diabetic foot ulceration, telemedicine has been introduced to facilitate the access of the patients to specialized health professionals. In this paper the development of an open source mobile health platform is presented, able to support diagnostic algorithms, with the use of a smartphone.