Wassim Mansour

Comparative study on carotid revascularization (endarterectomy vs stenting) using markers of cellular brain injury, neuropsychometric tests, and diffusion-weighted magnetic resonance imaging.

OBJECTIVE Subclinical alterations of cerebral function can occur during or after carotid revascularization and can be detected by a variety of standard tests. This comparative study assessed the relationship among serum levels for two biochemical markers of cerebral injury, postoperative diffusion-weighted magnetic resonance imaging (DW-MRI), and neuropsychometric testing in patients undergoing carotid endarterectomy (CEA) or carotid artery stenting (CAS) for high-grade asymptomatic carotid stenosis. METHODS Forty-three consecutive asymptomatic patients underwent carotid revascularization by endarterectomy (CEA, 20) or stenting (CAS, 23). They were evaluated with DW-MRI and the Mini-Mental State Examination (MMSE) test preoperatively and <or=24 hours after carotid revascularization. Venous blood samples to assess serum levels of neuron-specific enolase (NSE) and S100beta protein were collected for each patient preoperatively and five times in a 24-hour period postoperatively and assayed using automated commercial equipment. The MMSE test was repeated at 6 months. The relationship between serum marker levels and neuropsychometric and imaging tests and differences between the two groups of patients were analyzed by chi(2) test, with significance at P < .05. RESULTS No transient ischemic attacks or strokes were clinically observed. CAS caused more new subcortical lesions at postoperative DW-MRI and a significant decline in the MMSE postoperative score compared with CEA (P = .03). In CAS patients, new lesions at DW-MRI were significantly associated with a postoperative MMSE score decline >5 points (P = .001). Analysis of S100beta and NSE levels showed a significant increase at 24 hours in CAS patients compared with CEA patients (P = .02). The MMSE score at 6 months showed a nonsignificant increase vs the postoperative score in both groups. CONCLUSIONS Biochemical markers measurements of brain damage combined with neuropsychometric tests and DW-MRI can be used to evaluate silent injuries after CAS. The mechanisms of rise in S100beta and NSE levels at 24 hours after CAS may be due to increased perioperative microembolization rather than to hypoperfusion. Further studies are required to assess the clinical significance of those tests in carotid revascularization.

Silent stroke and cognitive decline in asymptomatic carotid stenosis revascularization.

The aim of this study was to assess the relationship between serum levels of S100β and neuron-specific enolase (NSE), postoperative diffusion-weighted magnetic resonance imaging (DW-MRI) and Mini-Mental State Examination (MMSE) score in asymptomatic patients affected by ≥70% carotid stenosis submitted to carotid endarterectomy (CEA) or carotid artery stenting (CAS), and to compare MMSE scores and DW-MRI findings at follow-up evaluations. Between April 2008 and April 2009, 60 patients were submitted to carotid intervention. All patients underwent DW-MRI and MMSE preoperatively, at 24 hours postoperatively, at 6 months and at 12 months. Neurobiomarkers were assessed for each patient at six time-points. Thirty-two patients were submitted to CEA and 28 to CAS. No mortality was observed. One CAS patient presented with an ischemic stroke. In six CAS patients and one CEA patient, new subclinical ischemic lesions were detected at postoperative DW-MRI (21.4% versus 3%, P = 0.03). In CAS patients, new DW-MRI lesions were significantly associated with MMSE score decline (P = 0.001). At 12 months, patients presenting with new postoperative ischemic lesions showed lower MMSE scores (P = 0.08). CAS patients showed increasing neurobiomarker levels compared with CEA patients (P = 0.02). In conclusion, microembolization effects may persist over time, so it should be avoided whenever possible. Carotid revascularization procedures should be evaluated and compared not only with respect to death/stroke but also to microembolism rates.

Preliminary Results from a National Enquiry of Infection in Abdominal Aortic Endovascular Repair (Registry of Infection in EVAR - R.I.EVAR)

BACKGROUND To preliminary report on epidemiology, risk factors, diagnosis, treatments, and outcomes in a multicenter series of patients treated for endovascular aortic repair (EVAR) infection and detected by an Italian National enquiry. METHODS From June 2012, 26 cases of abdominal aortic endograft infection were collected by a National Enquiry and recorded in the Italian National Registry of Infection in EVAR. Cases collected were available for patients submitted to EVAR implantation from January 2004 to June 2013. RESULTS Mean time from EVAR treatment to infection diagnosis was 20.5 ± 20.3 months (range, 1-72). In 6 cases (23.1%), an aortoenteric fistula (AEF) was detected. Positive microbiologic cultures were found in 20 patients (76.9%). More than 1 infectious agent was found in 6 cases (19.2%). EVAR infection treatment was conservative in 4 cases, endovascular in 2. Endograft excision was performed in 10 cases by conventional treatment (aortic stump + extra-anatomic bypass) and in 10 cases by in situ reconstruction (cryopreserved allograft or rifampin-soaked silver Dacron graft). A 30-day mortality was 38.4% (10 of 26 cases), 3 patients died from 2 to 24 months after infection treatment, accounting for a mean time from infection treatment to death of 1.25 ± 0.62 months. Mortality rates were 50% in all treatment groups. In those survived (13 of 26 cases) recurrence-free follow-up after infection treatment was 27.9 ± 22.4 months (range, 2-74). Four patients with AEF died in the first month after treatment (66.6%). Suprarenal endografts required supraceliac aortic cross-clamping for removal. Supraceliac cross-clamping was burdened by higher mortality rates than infrarenal cross-clamping (71.4% vs. 30.7%). CONCLUSIONS EVAR infection diagnosis is burdened by extremely high mortality rates. Prospective registries could help monitoring outcomes in EVAR infection patients and, possibly, developing new surveillance protocols in patients at high risk of recurrence.

Ten Years' Experience in Endovascular Repair of Popliteal Artery Aneurysm Using the Viabahn Endoprosthesis: A Report from Two Italian Vascular Centers

BACKGROUND Although rare, popliteal artery aneurysms (PAAs) are the most commonly observed peripheral arterial aneurysms. Surgical repair is considered the gold standard, even if with debated results. The aim of our study is to evaluate the outcome of endovascular treatment of PAAs using the Viabahn peripheral endograft (W. L. Gore and Associates, Inc., Flagstaff, AZ) in 2 high-volume Italian centers. METHODS All consecutive PAA patients treated by endovascular procedures between January 2004 and December 2013 were retrospectively reviewed. True atherosclerotic aneurysms, symptomatic and asymptomatic, were included in the analysis. All patients were treated by high-skilled vascular surgeons. The outcome measures were graft thrombosis, reintervention rate, and limb salvage at early and long-term follow-up. RESULTS Fifty-three PAAs were treated. Patients were more frequently male (98.1%) with a mean age of 73.6 ± 7.8 years. Twelve patients (22.6%) were symptomatic and in 8 of them a local fibrinolysis was required before definitive surgery. Mean PAA diameter was 30.9 ± 10.9 mm (range 17-60). Fifty-two patients (98.1%) had at least 1 patent runoff vessel. Technical success was achieved in all patients. Overall, 80 stent grafts were deployed and in 21 patients (39.6%) more than 1 stent graft was deployed. In-hospital mortality rate and 30-day reinterventions were null. At a mean follow-up of 37.4 ± 29.3 months, primary patency, secondary patency, and limb salvage were respectively 73.6%, 92.4%, and 100%. CONCLUSION In our limited, retrospective experience, the endovascular treatment of PAA by Viabahn stent graft allowed satisfactory technical and clinical results even at long-term follow-up.

Retrograde Type B Aortic Dissection as a Complication of Standard Endovascular Aortic Repair

Endovascular repair (EVAR) for abdominal aortic aneurysms (AAAs) is becoming the standard of practice in most vascular centers, even if some concerns remain about the occurrence of early and long-term failure and reintervention. A rare but potential catastrophic event is represented by retrograde type B aortic dissection (RTBAD). We report 2 cases of RTBAD after 425 standard EVARs performed in our institution. Both patients were treated for AAA without perioperative complication, and in both the patients, the presence of a preexisting disease of the thoracic aortic wall (ulcerated plaque in 1 case and aortic ectasia in the other) may have played an important role in the rapid evolution toward an early onset of the dissection. Only few cases of type B dissection after EVAR have been reported in literature, and the etiology of this complication remains uncertain. For the first time, our experience highlights the possible etiologic role of preexisting lesions of the thoracic aorta. In these cases, the only possible strategy may be to carefully study the entire aorta before an EVAR procedure, eventually switching the indication to an open surgical repair or carrying out a more aggressive management, treating the defects of the thoracic aorta.

Clinical and Functional Impact of Hypogastric Artery Exclusion During EVAR

Purpose: Hypogastric artery (HA) revascularization during endovascular aneurysm repair (EVAR) is still open to debate. Moreover, exclusion-related complication rates reported in literature are not negligible. The aim of this study is to present and analyze the outcomes in patients undergoing EVAR with exclusion of 1 or both HAs at our academic center. Methods: We retrospectively reviewed our results in patients submitted to EVAR and needing HA exclusion, in terms of perioperative (30-day) and follow-up rates of intestinal and spinal cord ischemia, buttock claudication, buttock skin necrosis, and sexual dysfunction. Results: From January 2008 to December 2014, a total of 527 patients underwent elective standard infrarenal EVAR; among those 104 (19.7%) had iliac involvement needing HA exclusion. In 73 patients with unilateral iliac involvement (70.1%, group UH), many single HAs were excluded. Thirty-one patients (29.9%) had bilateral iliac involvement (group BH), of which 16 (51.6%) had 1 HA excluded with revascularization of the contralateral one (group BHR); in the remaining 15 patients (48.4%) both HAs were excluded (group BHE). No 30-day or follow-up aneurysm-related mortality, intestinal, or spinal cord ischemia were recorded. At 30 days, skin necrosis was observed in 2 patients. Buttock claudication and sexual dysfunction rates were significantly greater in group BHE than in group BHR (P < .05). At a mean 18.6 months follow-up (range: 4-47), buttock claudication and sexual dysfunction rates in group BHE were persistently higher than that in groups UH and BHR (P < .05); HA coil embolization was significantly associated with buttock claudication and sexual dysfunction (P < .05). Conclusions: Whenever anatomically feasible, at least 1 HA should be salvaged in case of bilateral involvement. In case of unilateral HA exclusion, the rate of complications is not negligible. Coil embolization is related to a higher complication rate.

Endovascular treatment of a small infrarenal abdominal aortic aneurysm causing duodenal obstruction: Case report and literature review.

Duodenal obstruction caused by abdominal aortic aneurysm was first described by Osler in 1905 and is named “aortoduodenal syndrome.” This condition has always been treated by open surgical repair. We report the first case of aortoduodenal syndrome successfully treated by endovascular aneurysm repair. A 74-year-old male patient referred to our hospital complaining postprandial vomit, reporting a consistent weight loss in the latest weeks. Enhanced computed tomography scans showed a small saccular abdominal aortic aneurysm compressing duodenum and inferior vena cava without any other evident pathological finding. As the patient underwent a successful endovascular treatment of the abdominal aortic aneurysm, symptoms immediately resolved so that he started back to feed and progressively gained body weight. Despite aortoduodenal syndrome is generally caused by large abdominal aortic aneurysm, this condition has to be suspected also in case of small abdominal aortic aneurysm. Differently from what has been reported in literature, endovascular aneurysm repair could be effective in the treatment of aortoduodenal syndrome.

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.

Preoperative Intrasac Thrombus Load Predicts Worse Outcome after Elective Endovascular Repair of Abdominal Aortic Aneurysms

PURPOSE To evaluate the impact of two-dimensional and three-dimensional preoperative morphologic features analyzed on computed tomography (CT) angiography on midterm outcome in patients with abdominal aortic aneurysms (AAAs) treated with endovascular aneurysm repair (EVAR). MATERIALS AND METHODS A retrospective analysis was conducted using a prospectively collected database. Morphologic features considered as potentially influencing outcomes were maximum aortic diameter, thrombus area, overall aneurysm volume, and intrasac thrombus volume. Outcome measures were all perioperative and midterm AAA-related reinterventions and all-cause mortality. RESULTS Investigators reviewed 191 preoperative CT angiography scans. Mean maximum aortic diameter was 58 mm; thrombus area, 49.6%; aortic volume, 159.36 cm(3); and thrombus volume, 58.6%. Technical success was achieved in all cases. No reintervention was required in the perioperative period, and there was no perioperative mortality. At a mean follow-up of 32 months ± 16.8 (range, 3-66 mo), mortality rate was 9.4%, AAA-related death was 0, and reintervention rate was 8.9%. Causes of reintervention included type I endoleak (n = 3 [1.6%]), type II endoleak (n = 7 [3.7%]), type III endoleak (n = 1 [0.5%]), endograft limb thrombosis (n = 4 [2.1%]), and access vessel thrombosis (n = 2; 1%). Greater thrombus area (> 60%) and thrombus volume (> 59%) were predictors for reintervention (P = .005 and P = .0034). Greater maximum aortic diameter (> 59 mm) and aortic volume (> 159 cm(3)) were related to higher reintervention rate without statistical significance (P = .62 and P = .12). Aortic volume was a predictor of any adverse event, reintervention, and all-cause mortality after EVAR (P = .03). CONCLUSIONS Thrombus area and volume are related to higher rates of reintervention. Maximum aortic diameter was related to a higher reintervention rate, but this was not significant.

Contralateral Occlusion Increases the Risk of Neurological Complications Associated with Carotid Endarterectomy

Objective. To report on the incidence and factors associated with the development of perioperative neurological complications following CEA in patients affected by carotid stenosis with contralateral occlusion (CO) and to compare results between those patients and the whole group of patients submitted to CEA at our vascular division from 1997 to 2012. Methods. Our nonrandomized prospective experience including 1639 patients consecutively submitted to CEA was retrospectively reviewed. 136 patients presented a CO contralateral to the treated carotid stenosis. Outcomes considered for analysis were perioperative neurological death rates, major and minor stroke rates, and a combined endpoint of all neurological complications. Results. CO patients more frequently were male, smokers, younger, and symptomatic (P < 0.001), presented with a preoperative brain infarct and associated peripheral arterial disease (P < 0.0001), and presented with higher perioperative major stroke rate than patients without CO (4.4% versus 1.2%, resp., P = 0.009). Factors associated with the highest neurological risk in CO patients were age >74 years and preoperative brain infarct (P = 0.03). The combination of the abovementioned factors significantly increased complication rates in CO patients submitted to CEA. Conclusions. In our experience CO patients were at high risk for postoperative neurological complications particularly when presenting association of advanced age and preoperative brain infarction.