Vascular最新文献

Objectives: Carotid artery dissection (CAD) is a significant cause of strokes in young individuals, leading to severe complications and socioeconomic burdens. Despite antithrombotic therapy being the primary management strategy, optimal treatment for patients with recurrent or worsening symptoms remains undefined. This study aims to describe the characteristics and evaluate the outcomes of conservative versus surgical management in CAD patients.

Methods: A total of 23 patients presenting with CAD from November 2014 to December 2021 were reviewed retrospectively. Patient demographics, vascular risk factors, symptoms, imaging results, treatment details, and follow-up information were collected and analyzed. Propensity score matching (PSM) was utilized to enhance comparability.

Results: The mean age of the patients was 46.4 ± 9.4 years, with a median follow-up of 12 (range 3-90) months. Of the 23 patients reviewed, seven underwent endovascular treatment or open surgery due to unresponsiveness to conservative therapy, while 16 received conservative management. All patients showed regression of symptoms. Surgical patients showed a significant improvement with a 100% patency rate during the follow-up. PS matching adjusted for baseline differences, yielding comparable groups for analysis. No significant difference between treatment approaches was observed in stroke recurrence rates, although surgical intervention showed promising outcomes in symptom resolution and stroke prevention.

Conclusion: Both conservative and surgical management of CAD can lead to favorable outcomes. While conservative therapy remains the initial approach and proves effective, surgery appears beneficial and safe in certain cases unresponsive to conservative treatment. Further investigation through larger prospective and randomized trials is necessary to establish its safety and efficacy.

Background: Pseudoaneurysm of the cystic artery is very rare. It usually presents with rupture and hemorrhagic shock, which may be life-threatening. Ultrasonography and contrast-enhanced tomography can be used for the diagnosis. The mainstay of treatment for this disease is cholecystectomy.

Objective: Here we present an 86-year-old man with known diabetes and Alzheimer's disease whose pseudoaneurysm was treated with percutaneous thrombin injection and highlight the technical aspect of the procedure.

Method: With ultrasonography guidance, a 21-gauge Chiba needle was passed through the liver and advanced into the pseudoaneurysm sac. A controlled, slow injection of 0.5-cc thrombin into the sac was performed with instant occlusion. Doppler imaging performed immediately following the procedure revealed that the pseudoaneurysm was not filled.

Conclusion: Pseudoaneurysm of the gallbladder is extremely rare, and its diagnosis is difficult. If the condition is not treated right away, it can quickly become life-threatening. The majority of the pseudoaneurysms have already ruptured, and the patients are clinically septic, making surgery dangerous. Also, the use of contrast media in these patients may increase the risk of nephropathy, which is not an issue with percutaneous injection. Due to the obvious risk of rupture and bleeding, we propose injecting pseudoaneurysms only if they have a visible wall.

Result: Percutaneous injection of the gallbladder pseudoaneurysms can be an option when treating gallbladder pseudoaneurysms. More research on long-term success rates is required.

Purpose: To describe the technique of off-centering a balloon-expandable covered stent for selective occlusion of a distal entry tear (ET) in a patient, conservatively treated for chronic type B aortic dissection (cTBAD), presenting FL expansion.

Technique: A 63-year-old male, with conservatively managed cTBAD, presented at follow-up with FL partial thrombosis and expansion (thoracic aorta FL from 21 mm to 27 mm and abdominal aorta FL from 11 mm to 15 mm in 6 months). No proximal ET was identifiable. Distal FL perfusion was caused by an ET in the abdominal aorta feeding a 2 mm accessory renal artery (ARA). As the aortic diameter was below the threshold for endovascular repair, a selective occlusion of the distal ET and ARA was planned. A balloon-expandable covered stent was modified by off-centering the covered stent proximally and resulting in a funnel-shape occluder after deployment across the ET into the ARA. To prevent type Ic endoleak due to possible FL expansion caused by an intra-operatively detected phrenic artery (PA), coils were deployed into the lumen of the modified stent and the ARA. The pre-discharge computed tomography angiography showed exclusion of both the ARA and ET and a type 2 endoleak from the PA.

Conclusion: A balloon-expandable covered stent can be modified by off-centering the covered stent resulting in a funnel shape to adapt to different diameter requirements.

Background: Malnutrition is particularly pertinent in patients undergoing vascular surgery, who frequently present with a high burden of comorbidities and advanced age that can impede nutrient absorption. While previous studies have established that vascular surgery patients with malnutrition had poorer outcomes, the impact of nutritional status in patients undergoing endovascular aneurysm repair (EVAR) has not yet been investigated. Therefore, this study aimed to assess the effect of malnutrition on 30-day outcomes following non-ruptured EVAR.

Methods: Patients who had infrarenal EVAR were identified in the ACS-NSQIP targeted database from 2012-2022. Exclusion criteria included age less than 18 years, ruptured aneurysm, and emergency. Malnutrition was defined as patients with preoperative weight loss of greater than 10% decrease in body weight in the 6 months immediately preceding the surgery. A 1:5 propensity-score matching was used to match demographics, baseline characteristics, aneurysm diameter, distant aneurysm extent, anesthesia, and concomitant procedures between patients with and without malnutrition. Thirty-day postoperative outcomes were examined.

Results: There were 154 (0.94%) patients with malnutrition who went under non-ruptured EVAR. Meanwhile, 16,309 patients without malnutrition went under intact EVAR, where 737 of them were matched to all malnutrition patients. Malnourished patients had more comorbidity burdens. After propensity-score matching, patients with malnutrition had elevated but non-significant 30-day mortality (5.92% vs 2.99%, p = .09). However, malnutrition patients had higher risks of renal complications (2.63% vs 0.68%, p = .04), bleeding requiring transfusion (22.37% vs 14.38%, p = .02), and unplanned reoperation (11.18% vs 4.88%, p = .01), as well as longer length of stay (6.11 ± 7.91 vs 4.44 ± 6.22 days, p < .02).

Conclusion: Patients with malnutrition experienced higher rates of morbidity after non-ruptured EVAR. Targeting malnutrition could be a strategy for preventing complications after EVAR and proper preoperative malnutritional management could be warranted.

Background: To report revascularization of a superior mesenteric artery (SMA) ostial occlusion via the Arc of Buhler.

Case report: A 62-year-old female presented with 2 months of recurrent abdominal distension and postprandial pain. Computed tomography angiography (CTA) revealed ostial occlusion of the SMA with distal perfusion via the Arc of Buhler (connecting the celiac trunk and SMA). Conventional endovascular techniques failed. A 0.014 guidewire was passed retrograde through the occlusion via the Arc of Buhler. The guidewire was captured from the femoral sheath and balloon angioplasty with stent placement was performed. The patient had complete symptom resolution post-procedure.

Conclusions: Retrograde revascularization via the Arc of Buhler is an effective method for treating the initial segment occlusion of the SMA.

Objectives: We present two clinical cases of association between symptomatic free-floating thrombus (FFT) in thoracic aorta and rheumatoid arthritis (RA).

Methods: In the first patient, we observed a recent onset of peripheral and visceral signs of embolization: after a first treatment with anticoagulation, our Aortic team scheduled the coverage of FFT (sited in zone 1 of the aortic arch) with an anatomical debranching of anonymous trunk and left carotid artery, a left carotid-subclavian bypass, and a TEVAR of the aortic arch with proximal landing in zone 0 of the arch. The second case was characterized by chest pain, left upper limb ischemia, and CTA evidence of an FFT in zone 3 of the aortic arch; we planned a chimney-TEVAR on the left subclavian artery and descending thoracic aorta (with proximal landing in zone 2 of the aortic arch) to exclude the FFT.

Results: No complications resulted and no new embolic episodes were registered.

Conclusions: Evaluating the aorta is warranted in all patients with peripheral emboli of uncertain pathogenesis. In our opinion, the endovascular treatment of a symptomatic FFT could represent an effective and safe solution in a patient fit for endovascular surgery, but larger studies are required to define a personalized treatment strategy.