Journal of Endovascular Therapy最新文献

Purpose: We present the results of unconventional endovascular treatment of a voluminous (65 mm) saccular visceral aortic aneurysm in a 78-year-old woman. Patient was deemed unfit for open surgery due to comorbidities. Fenestrated or branched endografting was also excluded due to the small diameter of the aorta, the severe stenosis at the origin of celiac trunk, and the anomalous origin of superior mesenteric artery arising infrarenally.

Case report: After a preliminary selective angiography of the superior mesenteric artery showing valid anastomotic network with celiac trunk branches, an aortic self-expandable bare stent (Jotec E-XL) was deployed in the visceral aorta. Aneurysm sac embolization (Penumbra detachable Ruby Coils) in a coil-jailing technique was performed. Finally, an aortic cuff endograft (Gore) was deployed immediately above the origin of the left renal artery to cover the wide neck of the saccular aneurysm and improve sac exclusion. Hospital stay was uneventful, computed tomography (CT) at 12-month demonstrated aneurysm shrinkage to 62 mm without images of endoleak. Literature review showed how this technique has successfully been applied to manage similar cases of postsurgical and posttraumatic saccular aortic aneurysms in high-risk patients; however, long-term results are still unknown.

Conclusion: Coil-jail technique for the treatment of saccular aortic aneurysms can be considered an alternative when open surgery or conventional endovascular treatment is not feasible. Technical success and mid-term outcomes are promising but strict follow-up is recommended.

Clinical impact: This study aims to share the unconventional endovascular treatment of a visceral aortic aneurysm in a patient unfit both for open and traditional endovascular surgery. To the best of our knowledge this is one of the first cases published in Literature, for this reason, a step-by-step video has been created to describe the procedure. Literature review was then performed to analyze midterm results of this technique. Despite being a treatment that is not recommended for conventional cases, the knowledge of endovascular devices and techniques may help to manage or simplify complex aortic diseases.

Purpose: Brucella aneurysms are very rare but life-threatening, and a standard treatment approach has yet to be established. The current study aimed to assess the safety and efficacy of endovascular treatment for Brucella aneurysms.

Materials and methods: The clinical data of 15 Brucella aortic-iliac aneurysm patients who underwent endovascular repair at 2 hospitals from January 2012 to December 2021 were retrospectively collected and analyzed.

Results: Fifteen patients (12 men and 3 women) with a mean age of 59.3 years were included. Fourteen patients (93.3%) had a history of exposure to animals (cattle and sheep). All patients had aortic or iliac pseudoaneurysms, 9 abdominal aortic aneurysms (AAAs), 4 iliac aneurysms, and 2 AAA combined with iliac aneurysms. Endovascular aneurysm repair (EVAR) was performed in all patients without conversion to open surgery. Six cases were treated for emergency surgery due to aneurysm rupture. The immediate technique success rate was 100%, with no postoperative death. Two cases had the iliac artery ruptured again after operation because of lack of antibiotic treatment and was given endovascular treatment again. Once brucellosis is diagnosed, antibiotic treatment with doxycycline and rifampicin was initiated for all the patients until 6 months after operation. All patients survived over a median follow-up period of 45 months. Follow-up computed tomography angiography showed that all stent grafts remained patent, with no endoleak.

Conclusion: EVAR combined with antibiotics treatment is feasible, safe, and effective for Brucella aneurysms and represents a promising treatment option for these Brucella aneurysms.

Clinical impact: Brucella aneurysms are very rare but life-threatening, and a standard treatment approach has yet to be established. The traditional operation management strategy is surgical resection and debridement of the infected aneurysm and the surrounding tissues. However, open surgical management in these patients causes severe trauma with high surgical risks and mortality (13.3%-40%). We tried to treat Brucella aneurysms with endovascular therapy, and the technique success and survival rate of the operation reached 100%. EVAR combined with antibiotics treatment is feasible, safe, and effective for Brucella aneurysms and represents a promising treatment option for some mycotic aneurysms.

Purpose: The Clinical Frailty Scale (CFS), used to define frail patients, is significantly associated with clinical outcomes. The CFS can predict postoperative prognosis after cardiovascular procedures. However, no reports exist on the relationship between frailty defined by the CFS and thoracic endovascular aortic repair (TEVAR) outcomes.

Materials and methods: We analyzed data obtained from patients who underwent TEVAR between January 2011 and December 2021. Frailty was assessed using the 9-point CFS and was defined as a score of ≥5 points. The primary outcome was the 5-year overall survival rate. The secondary outcomes included the rate of freedom from aneurysm-related death at 5 years, postoperative complications, length of stay, rate of nonhome discharge, need for mobility assistance, 30-day mortality rate, and re-intervention rate.

Results: Of 331 patients who underwent TEVAR, 186 were included. The mean age of frail (n=36) and nonfrail (n=150) patients was 73.2 ± 7.3 years and 70.9 ± 9.0 years, respectively (p=0.15). The length of stay (17 [9-39] vs 11 [10-16] days; p=0.09) and re-intervention rate (8.3% vs 13.3%; p=0.58) were not significantly different, although frail patients had a higher rate of nonhome discharge (33.3% vs 4.7%; p<0.001), need for mobility assistance (38.9% vs 6.0%; p<0.001), and 30-day mortality (11.1% vs 0.7%; p=0.005) than nonfrail patients. The 5-year overall survival rate after TEVAR was 6.2 ± 5.5 and 84.5 ± 3.4% in frail and nonfrail patients (p<0.001). The median survival time was 22 (6-40) and 136 (87-138&x41; months, the number of recorded deaths in 5 years was 28 (77.8%) and 18 (12.0%; p<0.001), and the rate of freedom from aneurysm-related death at 5 years was 80.7%±11.2% and 96.9%±1.5% (p=0.01) in frail and nonfrail patients, respectively. The mean follow-up time was 53.3 ± 2.7 months. Multivariate Cox regression indicated that the CFS (hazard ratio, 10.14; 95% confidence interval, 5.06-20.32) was significantly associated with overall survival.

Conclusion: The CFS is a valuable prognosis predictor, and TEVAR for frail patients with a high surgical risk could not improve the overall survival. Thoracic endovascular aortic repair in frail patients should be approached cautiously.

Clinical impact: The Clinical Frailty Scale (CFS) could be a useful predictor of prognosis in patients undergoing thoracic endovascular aortic repair (TEVAR). A significant difference was observed between frail and nonfrail patients in the 5-year overall survival rate following TEVAR. Thoracic endovascular aortic repair for frail patients (CFS was ≥5 points) could not improve overall survival because their death was attributed to their comorbidities. Thus, TEVAR in frail patients should be approached cautiously.

Background and objectives: Endovascular aneurism repair (EVAR) is a minimally invasive alternative to open surgery for the treatment of abdominal aortic aneurysm. Iodine contrast medium (ICM) is considered the gold standard, at the high price of related nephrotoxicity and allergic reactions. Carbon dioxide (CO2) has been suggested as an alternative non-nephrotoxic contrast media agent. We aimed to evaluate the safety and the renal impact of the administration of CO2, compared with ICM in EVAR procedures.

Design, setting, participants, and measurements: We retrospectively reviewed data of patients who underwent EVAR at the Vascular Surgery Department of the Sant'Orsola Hospital in Bologna. Estimated glomerular filtration rate (eGFR) was evaluated before intervention, immediately after and at 12 months.

Results: In total, 22 patients received CO2 and low-dose ICM (CO2 Group) and 22 received standard ICM (Control Group), matched for clinical characteristics and renal function at the time of procedure. Pre and post-operative renal function values (eGFR) were compared between the two groups: in the immediate post-operative the group treated with CO2 and low-dose ICM globally showed a slight improvement in renal function (mean eGFR +5.10%±3.2), meanwhile the group treated with standard dose of ICM presented a significant worsening of renal function compared with pre-procedure values (mean eGFR -9.65%±4). Incidence of post-contrast acute kidney injury (PC-AKI) was 9% in the CO2 group vs 27% in the Control group. At 12 months, the renal impairment was significantly greater in the ICM group than in the CO2 group (mean eGFR decrease -19.2%±11.1 and -7.40%±3.5, respectively).

Conclusions: Administration of either CO2 alone or along with low-dose ICM showed to be safer than full-dose ICM alone, lowering the incidence of PC-AKI in patients undergoing EVAR. Unexpectedly, our study revealed also a significant worsening of renal function in patients treated with standard dose of ICM in 1-year follow-up, introducing the concept that acute renal damage caused by ICM could elicit a chronic injury process that affect long-term renal outcomes.

Clinical impact: Evaluating the safety and the renal impact of the administration of CO2, compared to Iodinate Contrast Medium, in EVAR procedures represents a first step in order to further tayloring medical procedures on patients characteristics. Our findings can guide the clinicians and surgeons in the procedures choice, not considering only the immediate effect of ICM on renal function but also the potential long-term effects.

Purpose: To gain insight into safety and efficacy of in situ and ex-situ fenestration techniques for total endovascular arch repair. The term ex-situ fenestration is referring to physician-modified stent-graft technique where fenestration is performed on a back table.

Methods: Electronic search was conducted according to PRISMA (Preferred Reporting Items for Systematic review and Meta-analyses) guidelines from 2000 to 2020. The main outcomes measured were 30-day mortality, stroke, aortic-related mortality, and reintervention rates.

Results: Fifteen studies were eligible: 7 ex-situ fenestration (189 patients) and 8 in-situ fenestration (149 patients). In ex-situ group, dissection was the main pathology treated and proximal sealing zones were Z0 or 1 in 53.5% of patients. In in-situ group, dissection and aneurysm were equally represented in around 40% of cases and proximal sealing zones were Z0 or 1 in 46.5% of patients. Cumulative 30-day all-cause mortality was similar in both groups: 3.8% (95% confidence interval [CI]: 1.7%-8.2%) and 3.8% (95% CI: 1.6%-8.9%), respectively, in ex-situ and in-situ groups and stroke rate of 2.8% (95% CI: 1.1%-7%) and 5.3% (95% CI: 2.6%-10.5%). After a 11.1 ± 2.6 months mean follow-up for ex-situ and 16.7 ± 2.3 months for in-situ group, there were 5.2 and 1.4 reinterventions per 100 patients-years, respectively, for ex-situ and in situ groups. Aortic-related mortality rates of, respectively, 3.2% (95% CI: 1.3%-7.4%) and 2.6% (95% CI: 0.9%-7.3%) were noted in ex-situ and in situ groups.

Conclusion: The reported data show favorable short-term results of both ex-situ and in-situ fenestration techniques with low mortality and strokes rates. However, durability is still questionable given the lack of long-term data. Both options may have their place in arch repair beyond the spectrum of emergent and urgent cases, on condition that results stand the test of time.

Clinical impact: In situ and ex-situ fenestration techniques have been initially developed to overcome emergency or as a bail out techniques however giving the promessing favorable short term results indications of these techniques may be extended to elective patients ineligible to customized stent-grafts and possibly in the futur to more elective cases as an option for total endovascular arch repair.

Purpose: The objective of this case is to report an endovascular occlusion of an acquired vascular fistula using an Amplatzer Vascular Plug II. Also, it is to review the available literature on risk factors, pathophysiology, and related management strategies about complications of the tunneled central venous catheter (TCVC).

Case report: The case was a 40-year-old man with a chronic kidney disease (CKD) on dialysis and with a history of several previous TCVC placements, along with recurrent infections. The last TCVC developed a fistula between the superior vena cava and the right pulmonary artery, shown by computed tomography (CT). We decided to remove a long-term TCVC and occluded the fistula applying an endovascular embolic device, an Amplatzer Vascular Plug II, subsequently. The patient was given parenteral treatment during 10 days of hospitalization. Over 9 months of follow-up, the device was appropriately positioned and did not obstruct the vascular flow.

Conclusion: Tunneled central venous catheters are frequently used for hemodialysis in patients in the last stage of CKD who do not have an arteriovenous fistula. Occasionally, delayed complications such as adherence or catheter migration occur. This case illustrates an endovascular treatment with excellent results and low risk of morbidity and mortality.

Clinical impact: The purpose of this work is to present an endovascular occlusion by means of an Amplatzer® Vascular Plug II in a residual fistula. The endovascular way is decided in situations, for instance, once the cardiothoracic surgeons argue that the patient is not in general conditions to tolerate surgery, the surgical procedure would be complex, or, in a surgical approach with a difficult-to-resolve hemorrhage. We explain the technique and the materials we used for an excellent result and a low risk of complications. This case is intended to serve as an aid in the treatment of similar events.

Purpose: Persistent sciatic artery (PSA) is a rare congenital vascular malformation with an incidence of approximately 0.025% to 0.04%. Persistent sciatic artery has major complications, such as aneurysms, thrombosis, and occlusion. Complications may lead to a range of serious clinical problems, and a timely diagnosis of this vascular variant is crucial to avoid life-threatening complications.

Case: A 65-year-old man was admitted to the hospital with pain and chills in the right lower extremity for 2 months, which gradually worsened. This was accompanied by numbness in the right foot for the last 10 days. Computed tomography angiography showed that the right inferior gluteal artery and right popliteal artery of the right internal iliac artery were connected, which is considered a congenital developmental variant. This was complicated by multiple thromboses of the right internal and external iliac arteries, and the right femoral artery. After admission to the hospital, the patient underwent endovascular staging surgery to relieve numbness and pain in the lower extremities.

Conclusion: Treatment strategies can be selected based on the anatomical characteristics of PSA and superficial femoral artery. Asymptomatic patients with PSA can be closely monitored. Surgery or individualized endovascular treatment plans should be considered for patients with aneurysm formation or vascular occlusion.

Clinical impact: For the rare vascular variation of the PSA, clinicians must make a timely and accurate diagnosis. Ultrasound screening is essential, which requires experienced ultrasound doctors to be aware of vascular interpretation and develop personalized treatment plans for each patient. In this case, we adopt staged a minimally invasive intervention to solve the problem of lower limb ischemic pain for patients. This operation has the advantages of rapid recovery and less trauma, which has important reference significance for other clinicians.

Purpose: Duplex ultrasound (DUS)-measured peak systolic velocity ratios (PSVRs) are commonly used to evaluate arterial stenosis in lower extremity artery disease (LEAD). However, these measurement methods have not yet been standardized. This study aimed to reveal the influence of measuring methods on PSVR values.

Methods: A 132 femoropopliteal lesions with PSVR ranging from 1.5 to 3.5 evaluated using method A (angle correction 60°, the direction of blood flow, the no or few atherosclerotic changes closest to the lesion proximal side was defined as the nonstenotic area) were included. The following 4 different methods were then compared with method A: method B, angle correction 45°; method C, angle correction 60° measured along the vessel wall; D, angle correction 60°, with the nonstenotic area the lowest peak systolic velocity area; and E, angle correction 60°, with the reference point fixed at 2 cm proximal to the target lesion area. The difference in PSVR values was analyzed using the Bland-Altman method.

Results: The mean PSVR value measured by method A was 2.27±0.51, those measured by methods B, C, D, and E were 2.21±0.55, 2.31±0.66, 2.34±0.63, and 2.11±0.63, respectively. The 95% prediction intervals of the differences in PSVR measurements versus A were -0.64 to +0.53 for method B, -0.59 to +0.68 for method C, -0.77 to +0.91 for method D, and -1.12 to +0.79 for method E.

Conclusion: PSVR values considerably differed between measuring methods. PSVR values by DUS are largely dependent on the measurement methods, which could considerably affect the judgment of LEAD.

Clinical impact: Due to differences in several DUS measurement methods, the PSVR results could be changed. Therefore, to need further investigations and unification of measurement method.