Walter Dorigo

Surgical treatment of visceral artery aneurysms: A 25-year experience

OBJECTIVE The aim of this study was to analyze our 25-year experience with surgical treatment of visceral artery aneurysms (VAAs), with particular attention paid to early and long-term results. MATERIALS AND METHODS From January 1982 to September 2007, 55 patients (32 males, 58%, and 23 females, 42%) underwent surgical treatment of 59 VAAs. Only one patient was treated with an endovascular procedure. Mean patient age was 59.3 years (range, 36-78 years). The site of aneurysmal disease was splenic artery in 30 (50.8%) cases, renal artery in nine (15.2%) cases, common hepatic artery in seven (11.9%) cases, pancreaticoduodenal artery in four (6.8%) cases, celiac trunk in three (5.1%) cases, superior mesenteric artery in two (3.4%) cases, and gastroduodenal, inferior mesenteric, middle colic and right gastroepiploic in one (1.7%) case for each artery. Two (3.6%) patients had multiple VAAs. In five (9.1%) patients, an abdominal aortic aneurysm coexisted. Early results in terms of mortality and major complications were assessed. Follow-up consisted of clinical and ultrasound examinations at 1 and 12 months, and yearly thereafter. Long-term results in terms of survival and aneurysm-related complications were analyzed. RESULTS In all but two cases, elective intervention in asymptomatic patients was performed. Two (3.6%) patients had a ruptured aneurysm (one pancreaticoduodenal artery and one middle colic artery). The one perioperative death was due to an acute pancreatitis in a patient operated on for a giant inflammatory splenic artery aneurysm, yielding a perioperative mortality rate of 1.8%. Two major complications (retroperitoneal hematoma and acute pancreatitis) were recorded. Mean duration of follow-up was 82.1 months (range, 0-324 months). Estimated 10-year survival rate was 79.5%. During follow-up two aneurysm-related complications occurred, with an estimated 10-year, aneurysm-related, complication-free survival rate of 75.2%. CONCLUSION In the era of minimally invasive therapeutic approaches, elective open surgical treatment of visceral artery aneurysms is safe and effective, and offers satisfactory early and long-term results.

A Multicentric Experience with Open Surgical Repair and Endovascular Exclusion of Popliteal Artery Aneurysms

INTRODUCTION The aim of this study was to analyse early and follow-up results of the treatment of popliteal artery aneurysms (PAAs) performed with open surgical repair or with endovascular exclusion with endografts in a multicentric retrospective registry involving seven Italian vascular centres. MATERIALS AND METHODS We retrospectively collected data concerning 178 open surgical interventions (OR group) and 134 endovascular exclusions (ER group) for PAAs performed between January 2000 and December 2011. Early and follow-up results were analysed in terms of mortality, graft patency, reintervention and limb preservation. RESULTS OR patients were more frequently symptomatic (64%, 115 cases) than patients in the ER group (34%, 51 cases; p < 0.001), had more frequently acute limb ischaemia (23% and 6.5%, respectively; p < 0.001) and had more frequently a run-off score <2 (39% and 26%, respectively, p = 0.03). In the OR group there were no perioperative deaths; six thromboses (3.3%) and one amputation occurred. In the ER group mortality was 1.5%; 13 thromboses (9.7%) and one amputation (0.5%) occurred. Mean duration of follow-up was 30.6 ± 27.5 months. In the OR group primary and secondary patency, freedom from reintervention and limb preservation rates at 48 months were 63.5% (standard error (SE) 0.05), 76.5% (SE 0.05), 72.5% (SE 0.06) and 89.7% (SE 0.05), respectively. The corresponding figures in the ER group were 73.4% (SE 0.04), 85% (SE 0.04), 75% (SE 0.04) and 97% (SE 0.04), respectively. CONCLUSIONS In this large multicentric retrospective registry, open and endovascular treatment of PAAs are used in different patients with regard to clinical and anatomical characteristics. Both treatments are feasible and safe, providing satisfactory early and long-term results.

A multicenter comparison between autologous saphenous vein and heparin-bonded expanded polytetrafluoroethylene (ePTFE) graft in the treatment of critical limb ischemia in diabetics

OBJECTIVES The aim of this study was to evaluate early and follow-up results of below-knee bypasses performed using a bioactive heparin-treated expanded polytetrafluoroethylene (ePTFE) graft in diabetic patients with critical limb ischemia (CLI) in a multicenter retrospective registry involving seven Italian vascular centers and to compare them with those obtained in patients operated on with autologous saphenous vein (ASV) in the same centers in the same period of time. METHODS Over an 8-year period, ending in 2009, a heparin-bonded prosthetic graft (Propaten Gore-Tex; W. L. Gore & Associates Inc, Flagstaff, Ariz) was implanted in 180 diabetic patients undergoing below-knee revascularization for CLI in seven Italian hospitals (group 1). In the same period in these seven centers, 133 below-knee bypasses with ipsilateral ASV in diabetics with CLI were performed (group 2). Data concerning these interventions were retrospectively collected in a multicenter registry with a dedicated database. Early (<30 days) results were analyzed in terms of graft patency, major amputation rates, and mortality. Follow-up results were analyzed in terms of primary and secondary graft patency, limb salvage, and survival. RESULTS The interventions consisted of below-knee bypasses in 132 cases in group 1 (73%) and in 45 cases in group 2 (33%; P < .001); 48 patients in group 1 (27%) and 88 patients in group 2 (67%; P < .001) had distal tibial anastomosis. Patients in group 1 had more frequently adjunctive procedures performed at distal anastomotic sites to improve run-off status. Postoperative and long-term medical treatment consisted of single antiplatelet therapy in 93 cases (52%) in group 1 and in 64 cases (48%, P = ns) in group 2, of double antiplatelet therapy in 18 cases (10%) in group 1 and in four cases (3%; P = .05) in group 2 and of oral anticoagulants in 69 patients in group 1 (38%) and in 65 (49%; P = .02) in group 2. Mean duration of follow-up was 28.3 ± 21.4 months; 308 patients (98%) had at least one postoperative clinical and ultrasonographic examination and 228 (72%) reached at least a 1-year follow-up. Estimated 48-month survival rates were 76.6% in group 1 and 72.7% in group 2 (P = > .9, log-rank 0.08). Primary patency rate at 48 months was significantly better in group 2 (63.5%) than in group 1 (46.3%; P = .03, log-rank 4.1). Assisted primary patency rates at 48 months were 47.3% (SE 0.05) in group 1 and 69% (SE 0.05) in group 2 (P = .01, log-rank 6.3). The rates of secondary patency at 48 months were 57.5% in group 1 and 69.6% in group 2 (P = .1, log-rank 2.3); the corresponding values in terms of limb salvage and amputation free-survival rates were 75.4% and 82.4% (P = .3, log-rank 1), and 59.9% and 64.4% (P = .3, log-rank 0.9), respectively. CONCLUSIONS Data from this large, retrospective registry confirmed that the indexed heparin-bonded ePTFE graft provides satisfactory early and midterm results in diabetic patients undergoing surgical treatment of CLI. While autologous saphenous vein maintains its superiority in terms of primary patency, secondary patency rates are not statistically different, even in the presence of a trend for improved secondary patency with vein graft; and also limb salvage rates are comparable.

Midterm results from a multicenter registry on the treatment of infrainguinal critical limb ischemia using a heparin-bonded ePTFE graft

OBJECTIVES To report midterm results of infrainguinal bypasses performed with a heparin-bonded expanded polytetrafluoroethylene (ePTFE) graft in patients presenting with critical limb ischemia. METHODS Over a 7-year period ending in 2008, 425 patients presenting with critical limb ischemia underwent infrainguinal revascularization using a heparin-bonded ePTFE graft in seven Italian vascular centers. Preoperative, intraoperative, and follow-up data were collected in a multicenter registry. Patients were predominantly male (79%) with a mean age of 73.5 years. Mean preoperative ankle brachial index (ABI) was 0.35 and 192 of the patients (45%) were diabetic. Intervention consisted of a femoral to below-knee bypass in 324 patients (76%), whereas the remaining 101 patients had a femoral to above-knee bypass. In patients with below-knee bypass, distal target vessels were the popliteal artery in 238 cases, the tibioperoneal trunk in 38 cases, and a tibial vessel in the remaining 48 cases (anterior tibial artery in 20 cases, posterior tibial artery in 23 cases, and peroneal artery in 5). Follow-up consisted of clinical and duplex scanning examinations within 3 months from the intervention and yearly thereafter. Early (<30 day) results were analyzed in terms of deaths, graft thromboses, and amputations with univariate and multivariate (stepwise logistic regression) analysis. Follow-up results were evaluated in terms of primary and secondary graft patency, limb salvage, and survival rate with univariate and multivariate (Cox regression) analysis. RESULTS Thirteen perioperative deaths occurred (3.1%). Thirty-day primary graft patency was 92.5% and limb salvage was 95.8%. Follow-up was available in 98% of patients with a median duration of 25.5 months (SD, 17.6; range, 1-72). Cumulative estimated 36-month primary and secondary patency, limb salvage, and survival rates were 61%, 70%, 83%, and 83%, respectively. At univariate analysis, the factors associated with poorer limb salvage rates during follow-up were the presence of ischemic ulcers or gangrene (log-rank, 8.4; P = .004; 95% confidence interval [CI] 1.2-3.5; odds ratio [OR], 2.1), the presence of only one patent tibial vessel (log-rank, 41.3; P < .001; 95% CI, 3.1-10.8, OR, 5.8), redo surgery (log-rank, 12.4; P < .001; 95% CI, 1.4-4; OR, 2.4) and the postoperative treatment with antiplatelet therapy in comparison to oral anticoagulants (log-rank, 5.1; P = .02; 95% CI, 1.0-3.4; OR, 1.8). At multivariate analysis redo surgery (P = .02; 95% CI, 1.1-3.1; OR, 1.8), poor runoff score (P < .001; 95% CI, 2.5-9.1; OR, 4.7) and preoperative clinical status (P = .02; 95% CI, 1.1-3.1; OR, 1.8) were independently associated with decreased limb salvage rates. CONCLUSION The use of a heparin-bonded ePTFE graft provides good early and midterm results, with low rates of late amputations. Primary and secondary patency made this graft an excellent alternative to autologous saphenous vein when it is absent, unsuitable, or of poor quality.

Early and long-term results of surgical treatment of splenic artery aneurysms

BACKGROUND This retrospective study was conducted to describe the presentation, surgical treatment, and follow-up of patients with splenic artery aneurysms. METHODS From 1982 to 2000, 1,952 patients with abdominal aneurysms were referred to our department; 15 had splenic artery aneurysms. None had ruptured. All were operated on. RESULTS Fourteen complete and 1 partial aneurysmectomies were carried out. Arterial continuity was restored in 10, by end-to-end anastomosis, and 4 had splenectomies. In 1 patient the spleen was preserved without arterial reconstruction. There were no deaths. Morbidity was restricted to 1 patient with a limited, asymptomatic splenic infarction. Eleven patients were followed up for a mean 19.7 months. No deaths or major complications were recorded. Reconstructed splenic arteries were patent in all cases without atrophy or new cases of splenic infarction. CONCLUSIONS Elective surgery for splenic artery aneurysms is safe. Arterial reconstruction allows good early and long-term results. In some cases splenectomy may be unavoidable.

Endovascular Aortic Aneurysm Repair with the Endurant Stent-graft: Early and 1-year Results from a European Multicenter Experience

PURPOSE To assess preliminary results of the Endurant stent-graft, which was developed to treat patients with abdominal aortic aneurysms (AAAs) and challenging aortoiliac anatomy. MATERIALS AND METHODS From November 2007 to October 2008, 45 patients with AAAs were treated with the Endurant stent-graft in three European vascular centers. Thirty-eight of the 45 patients (84%) had a hostile anatomy of the proximal neck. Early (30 days), early midterm (6 months), and late midterm (1 year) results were analyzed in terms of technical success, clinical success, morbidity, and mortality. RESULTS Intraoperative immediate technical and clinical success was achieved in all cases. At completion angiography, a type II endoleak was detected in seven of the 45 patients (16%) and an iliac limb stenosis was diagnosed and successfully treated in five (11%). At discharge, computed tomography demonstrated a type I endoleak in one of the 45 patients (2.2%). At 30 days, a graft limb thrombosis was diagnosed (2.2%) and successfully treated. The 30-day overall technical and clinical success rates were 97.8% (44/45 cases) and 95.6% (43/45 cases), respectively. During follow-up (mean duration, 8 months; range, 5-16 months), the type I endoleak was successfully treated with an aortic extension. Estimated freedom from type I or III endoleak and repeat intervention at 1 year was 97.8% (44/45 cases) and 93.3% (42/45 cases), respectively. CONCLUSIONS The initial experience shows that the Endurant stent-graft appears to be effective in endovascular repair of AAAs in patients with hostile aortoiliac anatomy. This graft permits a broader group of patients to be treated with endovascular aneurysm repair; however, further studies are needed to evaluate the long-term results.

Early and long-term comparison of endovascular treatment of iliac artery occlusions and stenosis

OBJECTIVES This study evaluated early and long-term results of endovascular treatment of iliac artery occlusions and compared these outcomes with those in patients treated for stenotic lesions. METHODS During a 10-year period ending in January 2010, 223 endovascular procedures to treat aortoiliac occlusive disease (PAD) were performed. All patients were prospectively enrolled in a dedicated database. The intervention was performed for iliac occlusion in 109 patients (group 1) and for iliac stenosis in 114 (group 2). Early results were analyzed and compared by χ² and Fisher exact tests. Follow-up consisted of clinical examination and duplex scanning at discharge, ≤ 3 months, at 6 and 12 months, and yearly thereafter. Follow-up results were analyzed with Kaplan-Meier curves and compared with the log-rank test. RESULTS The two groups had similar risk factors for atherosclerosis and comorbidities. Critical limb ischemia was more common in group 1 (20.5%) than in group 2 (8.5%; P = .01). Intraoperative technical details were similar, except for a higher percentage of brachial and contralateral femoral access and more frequent use of nitinol stents in group 1. Two immediate technical failures occurred, one in both groups, requiring immediate conversion to surgical bypass. Four intraoperative iliac ruptures occurred, two in each group; all were successfully treated with covered stents. An additional 10 immediate complications occurred (8 in group 1; 2 in group 2), one of which required conversion to open surgical bypass. The cumulative rate of perioperative complications was 9% in group 1 and 3.5% in group 2 (P = .08). Primary patency at 30 days was 97.3% and 98.7%, respectively. Mean duration of follow-up was 28.4 months; 203 patients (91%) had a regular postoperative follow-up visit. At 60 months, primary patency in group 1 vs group 2 was 82.4% vs 77.7% (P = .9), assisted primary patency was 90.6% vs 85.5% (P = .4), and estimated secondary patency was 93.1% vs 92.8% (P = .3). The cumulative rate of reintervention during follow-up (excluding reinterventions performed in the perioperative period) was 2.5% in group 1 and 12.5% in group 2 at 60 months (P = .09). Univariate analysis in group 1 failed to find any of the examined risk factors significantly affected long-term primary patency rates. CONCLUSIONS In our experience, endovascular treatment of iliac occlusions provides excellent early and long-term results, similar to those obtained in the treatment of stenotic lesions.

Early and Long-term Results of Conventional Surgical Treatment of Secondary Aorto-enteric Fistula

OBJECTIVE To retrospectively evaluate early and late results of surgical treatment of secondary aorto-enteric fistulas (SAEFs) with prosthetic excision and extra-anatomic bypass (conventional treatment) in a single centre institution (teaching hospital). MATERIALS AND METHODS Between January 1990 and March 2002, 30 patients underwent conventional surgical treatment for SAEF. Data concerning these operations were collected in a dedicate database and 30-day mortality, patency and limb salvage rates were evaluated by mean of chi-square test and logistic regression analysis. Clinical and ultrasonographic follow-up was performed; late results were evaluated by mean of Kaplan-Meyer curves. RESULTS Thirty day mortality rate was 26% (8 patients). Timing and sequence of interventions (simultaneous or staged, prosthetic excision or revascularization before) had no significative influence on perioperative mortality. There were six extranatomic bypass thromboses at 30 days, but no amputation. Mean duration of follow-up was 24 months; estimated 12- and 24-month survival rates were 60 and 50%, respectively. There were better results in terms of long-term survival in patients undergone prosthetic graft excision before. Primary patency rate was 62% and limb salvage rate was 95%, both at 24 months. Two prosthetic graft reinfections occurred during follow-up (9%). Cumulative reinterventions rate during follow-up was 18%. CONCLUSIONS Conventional surgical treatment of SAEF permitted, in our experience, satisfactory early and long terms results, with fair rates of patency and limb salvage. Surgical timing and sequence do not seem to affect early results.

Comparison of Early and Midterm Results of Open and Endovascular Treatment of Popliteal Artery Aneurysms

BACKGROUND Aim of this study was to retrospectively compare perioperative (<30 days) and 2-year results of open and endovascular management of popliteal artery aneurysms (PAAs) in a single-center experience. METHODS From January 2005 to December 2010, 64 PAAs in 59 consecutive patients were operated on at our institution; in 43 cases, open repair was performed (group 1), whereas the remaining 21 cases had an endovascular procedure (group 2). Data from all the interventions were prospectively collected in a dedicated database, which included main preoperative, intraoperative, and postoperative parameters. Early results in terms of mortality, graft thrombosis, and amputation rates were analyzed and compared by χ(2) text or Fisher exact text. The surveillance program consisted of clinical and ultrasonographic examinations at 1, 6, and 12 months and yearly thereafter. Follow-up results (survival, primary and secondary patency, limb salvage) were analyzed by Kaplan-Meier curves, and differences in the two groups were assessed by log-rank test. RESULTS There were no differences between the two groups in terms of sex, age, risk factors for atherosclerosis, and comorbidities; PAAs were symptomatic in 48% of cases in group 1 and in 29% in group 2 (P = 0.1). Fifteen patients with mild-to-moderate acute ischemia due to PAA thrombosis underwent preoperative intra-arterial thrombolysis, 13 in group 1 and 2 in group 2. In open surgery group, nine cases were treated with aneurysmectomy and prosthetic graft interposition, and in seven cases, the aneurysm was opened and a prosthetic graft was placed inside the aneurysm. In 27 cases, ligation of the aneurysm with bypass grafting (21 prosthetic grafts and 6 autologous veins) was carried out. In group 2, 20 patients had endoprosthesis placement, whereas in the remaining patient, a multilayer nitinol stent was used. There was one perioperative death in a patient of group 2 who underwent concomitant endovascular aneurysm repair and PAA endografting. Cumulative 30-day death and amputation rate was 4.5% in group 1 and 4.7% in group 2 (P = 0.9). Follow-up was available in 61 interventions (96%) with a mean follow-up period of 22.5 months (range: 1-60). Estimated primary patency rates at 24 months were 78.1% in group 1 and 59.4% in group 2 (P = 0.1). Freedom from reintervention rates at 24 months were 79% in group 1 and 61.5% in group 2 (P = 0.2); estimated 24-month secondary patency rates were 81.6% in group 1 and 78.4% in group 2 (P = 0.9), and freedom from amputation rates were 92.7% and 95%, respectively (P = 0.7). CONCLUSIONS Endovascular treatment of PAAs provided, in our initial experience, satisfactory perioperative and 1-year results, not significantly different from those obtained with prosthetic open repair in patients with similar clinical and anatomical status. There is, however, a trend toward poorer primary patency rates among patients endovascularly treated, who also seem to require more frequently a reintervention.

Gender-related outcomes in the endovascular treatment of infrainguinal arterial obstructive disease

OBJECTIVE The purpose of this study was to retrospectively analyze early and midterm results of endovascular infrainguinal peripheral revascularizations in female patients in our single-center experience, paying particular attention to clinical, anatomic, and technical factors affecting perioperative and follow-up outcomes. MATERIALS AND METHODS From January 2000 to December 2010, 258 endovascular interventions for femoropopliteal disease were performed. Interventions were retrospectively divided into two groups: interventions performed in women (80 interventions, group 1) and interventions performed in men (178 interventions, group 2). The two groups of patients were compared in terms of demographic data, common risk factors for atherosclerosis, and comorbidities. Early (intraoperative and <30-day) results were analyzed in terms of technical success, conversion to open surgery, primary patency, secondary patency, and, for patients with critical limb ischemia, limb salvage. The follow-up program consisted of clinical and duplex scanning examinations with ankle-brachial index (ABI) measurement within the third postoperative month, at 6 and 12 months, and yearly thereafter. Follow-up results were analyzed in terms of survival, primary and secondary patency, assisted primary patency, and, for patients with critical ischemia, limb salvage. RESULTS There were no differences between the two groups in terms of risk factors for atherosclerosis, comorbidities, clinical, and anatomic status. Technical success was 96.9% and technical failure rates were 1.2% in group 1 and 3.9% in group 2 (P = .2). Three in-hospital deaths were recorded, all in group 2, whereas in-hospital thromboses occurred in five patients, two in group 1 and three in group 2; with conversion to surgical bypass in all these cases, and in three of the cases, major amputation was necessary (two in group 1 and one in group 2). Cumulative 30-day mortality was 1.1%, with no difference between women (no deaths) and men (three deaths, 1.6%; P = .4). Overall amputation rate at 30 days was 1.2%, again with no differences between the two groups (2.5% and 0.6%, respectively; P = .4); also, the rate of perioperative thrombosis (overall 2.7%) was similar between the two groups (2.5% and 3.3%, respectively; P = .9). Mean duration of follow-up was 17 months (range, 1-85 months). Estimated 36-month survival rates were 95% in group 1 and 84.5% in group 2 (P = .4; log-rank, 0.7). Cumulative primary patency rates at 36 months were 38% in group 1 and 42% in group 2 (P = .4; log-rank, 0.5). Assisted primary patency at 36 months was 45.1% in group 1 and 60.5% in group 2, whereas secondary patency rates were 63.5% and 76%, respectively (P = .8; log-rank, 0.03). CONCLUSION Endovascular treatment of femoropopliteal occlusive disease provides similar results between men and women at an intermediate follow-up. There is, however, a trend toward poorer results in women requiring further analysis at a longer follow-up period.