Vascular and endovascular surgery最新文献

Introduction: Subclavian artery (SCA) aneurysms are rare, accounting for less than 1% of peripheral aneurysms. Repair is indicated due to the risk of complications. Methods: The electronic medical records in our institution were reviewed and the case of a patient with large right SCA is presented.Results: An 80 year-old female, with complex medical history, presented with a large right SCA aneurysm. She was deemed high risk for open repair and underwent innominate and common carotid artery stent graft placement, embolization of the sac, and carotid to axillary artery bypass. Her clinical course was complicated by an atheroembolic multiterritorial stroke, and she was found to be clopidogrel resistant. She was discharged to a rehabilitation facility and was recovering well at 3 months after surgery.Conclusion: Detailed and careful pre-operative planning, as well as familiarity with the different surgical approaches is necessary for the best outcomes.

ObjectivePost-operative pneumoperitoneum is mainly related to gastrointestinal perforation, although non-surgical pneumoperitoneum may also be present, with mechanical ventilation being the leading cause. Herein, we report a case of non-surgical pneumoperitoneum after percutaneous fenestrated endovascular aortic repair (fEVAR).Case reportA 79-year-old female presented with a 58 mm asymptomatic juxtarenal abdominal aortic aneurysm. The preoperative computed tomography angiography (CTA) detected also a diaphragmatic hernia. According to the latest guidelines, an indication for fEVAR was set. The successful implantation of a four-fenestrated custom-made endograft was performed using bilateral percutaneous femoral access. Even though the immediate postoperative period was uneventful, the predischarge CTA revealed a high-volume pneumoperitoneum and pneumomediastinum. The patient developed mild tenderness of the lower abdomen during palpation, and a postoperative elevation of the C-reactive protein (CRP = 205 mg/L) was identified. After general surgery consultation, an exploratory laparoscopy with intraoperative gastro-duodenoscopy were performed, which revealed no evidence of gastrointestinal perforation. The patient was discharged in good general condition on the sixth postoperative day.ConclusionPost-operative pneumoperitoneum may be related to mechanical ventilation due to alveolar injury after fEVAR. Laboratory and imaging findings should be judged in the influence of clinical image. An initial watch and wait approach may be justified.

Background: Asymptomatic compression of celiac artery (CA) by median arcuate ligament (MAL) is quite common, but simultaneous compression of other arteries by MAL is very rare. Case details: A 20-year-old man presented with post-prandial epigastric pain for the past 1 year and a 5 kg weight loss. On examination, he had a body mass index of 17.2 kg/m² and was normotensive. Blood tests were unremarkable except for a mildly raised serum creatinine. A CT angiography (CTA) showed MAL-related 60% proximal CA narrowing and 40% proximal right renal artery (RRA) narrowing with a small right kidney. After multi-disciplinary team discussion, surgical MAL release at both sites was planned. The surgery was started laparoscopically to identify CA origin by a 'top to down' approach. The CA origin could not be visualised as it was looping behind the pancreatic neck caudally; hence the procedure was converted to open. CA origin was identified and overlying MAL divided. After kocherisation, RRA origin was found compressed by right limb of MAL and was divided. The operative duration was 200 mins with 50 mL blood loss. Results: The patient had an uneventful recovery. At 12-month, he is asymptomatic with serum creatinine normalised and gained 8 kg weight. A follow-up CTA at 2 months showed a normal CA and RRA. In this report, we discuss briefly about the current presentation, diagnosis and treatment of MAL compression of CA and other upper abdominal arteries. Conclusions: The learning point from this case is that one should carefully inspect all upper abdominal arteries in CTA for MAL-related compression as they may be asymptomatic, and this enables simultaneous treatment at these sites too in a single surgery.

Fenestrated endovascular repair (FEVAR) has become a safe and effective option for the treatment of complex aortic aneurysms (CAA). Complications can occur, including endoleaks like type IIIc endoleak, characterized by flow between a fenestration and its bridging stent. Although some endoleaks may resolve spontaneously, most require secondary interventions to prevent further expansion of the aneurysmal sac and other complications. We describe a percutaneous "stent-and-plug" rescue maneuver performed in 5 consecutive patients with refractory type IIIc endoleaks after company-manufactured FEVAR grafts. Under moderate sedation and bilateral femoral access, the target-vessel stent was balloon-protected while the free space of the fenestration causing the endoleak was catheterized contralaterally; a 5 × 16 mm iCast™ stent was deployed within the fenestration, and an Amplatzer vascular plug was positioned inside the new stent. Then, the renal-stent balloon was re-inflated to crush the stent-plug complex and achieve a seal in the fenestration. Endoleaks emerged at a mean of 2.47 months (range 1.10-7.1) after the index repair, persisting despite one (n = 3) or 2 (n = 2) prior angioplasty or re-stenting attempts. The stent-and-plug technique achieved technical success in 4 of the 5 cases; the remaining case required one additional procedure to achieve complete sealing. No renal branch occlusion, dialysis-requiring renal injury, or procedure-related mortality occurred. The mean follow-up after rescue was 8.96 months (range 1.4-15.3), with no sac growth observed. Stenting and plugging the fenestration-free space offers a feasible option for treating persistent type IIIc endoleaks when conventional secondary interventions fail; extended surveillance is necessary to confirm long-term durability.

Background and PurposeSecondary aorto-enteric fistulas (SAEF) are the most severe form of aortic graft infection, with a mortality of over 50% during the first year after diagnosis.Materials and MethodsA retrospective review of patients treated for SAEF from 2015 to 2021 in University Hospital Centre Zagreb was done to analyze factors that determine the outcome. There were 7 cases of SAEF among 400 cases of open aortic surgery. Mean patient age was 69 years (range 63-88).ResultsFive patients underwent graft removal and in-situ aortic reconstruction using a cryopreserved homograft or a prosthetic Dacron silver graft (Vascutec Gelsoft Plus, Terumo, Tokyo, Japan). In 1 patient direct suture repair of the fistula was done, and the patient underwent recurrent SAEF reconstruction with cryopreserved homograft a year later. There were 3 recurrences of SAEF in 2 patients, 1 case of disruption of the duodenal suture line, and 1 case of cryopreserved graft necrosis and rupture necessitating emergency extra-anatomic bypass. Overall, 1 patient died during surgery (in-hospital mortality 1/7, 15%), and 3 patients are currently alive (follow-up 4-5 years). Overall 1-month survival, 1-year survival and 3-year-survival were 6/7 (85%). All patients received antibiotics for 6 weeks postoperatively.ConclusionThere is no unique, the best, treatment modality proven in the literature for SAEF, so every case should be analyzed for itself. Prolonged antibiotic therapy, complications and re-interventions are common among these patients, so meticulous follow-up is necessary.

BackgroundDiabetic foot ulcers (DFUs) complicated by critical limb ischemia (CLI) present a major therapeutic challenge, especially when associated with chronic total occlusions (CTOs) of below-the-knee (BTK) arteries or vascular lesions such as pedal pseudoaneurysms and arteriovenous fistulas (AVFs). While endovascular techniques have expanded the therapeutic landscape, such anatomically complex cases require tailored, multidisciplinary strategies to achieve successful limb salvage.Case PresentationWe report the case of a 52-year-old male with type II diabetes mellitus, end-stage renal disease (ESRD), and a chronic non-healing DFU. Imaging revealed a CTO of the posterior tibial artery (PTA) and pedal-plantar loop, significant stenosis of the dorsalis pedis artery (DPA), and a distal metatarsal artery pseudoaneurysm with an AVF. The patient underwent successful retrograde endovascular recanalization using the pedal-plantar loop technique and flossing-wire method, followed by balloon angioplasty of the DPA and PTA. Coil embolization of the pseudoaneurysm and AVF was performed using a sandwich technique.OutcomeThe patient experienced no peri-procedural complications. Perfusion parameters improved significantly, and complete wound healing was achieved during follow-up. No recurrence, re-intervention, or amputation occurred within 12 months.ConclusionThis case highlights the feasibility and effectiveness of a fully endovascular, hybrid approach for managing complex BTK occlusions combined with distal vascular lesions. The integration of revascularization and targeted embolization in a single session can optimize outcomes in patients with limb-threatening DFUs.

BackgroundCarotid endarterectomy (CEA) is recommended as the standard revascularization strategy for patients with carotid stenosis, whereas carotid artery stenting (CAS) is generally reserved for high-risk surgical candidates. However, evidence comparing the safety and efficacy of both approaches in real-world practice remains heterogeneous.MethodsWe retrospectively analyzed 202 patients (mean age: 71.1 ± 8.5 years; 152 males, 75.2%) who underwent carotid revascularization at a single center between October 2016 and April 2025. Patients with symptomatic moderate-to-severe stenosis (50-99%) and asymptomatic severe stenosis (70-99%) were included. Based on the revascularization strategy, patients were divided into CEA (n = 67) and CAS (n = 135) groups. Periprocedural (30-day), 1 and 3-year outcomes including stroke, myocardial infarction (MI), and all-cause mortality were evaluated.ResultsAmong patients, periprocedural stroke occurred in 4.5% of CEA patients and 2.2% of CAS patients (P = 0.653), MI in 1.5% and 0%, (P = 0.720), and all-cause mortality in 4.5% and 0.7% (P = 0.208) respectively. At 1-year follow-up, MI was significantly more frequent after CEA compared with CAS (8.6% vs 1.5%, P = 0.029), whereas stroke (8.6% vs 5.3%, P = 0.387) and all-cause mortality (10.3% vs 12.9%, P = 0.622) did not differ significantly. At 3 years, rates of stroke (12.3% vs 5.3%), MI (10.3% vs 3.8%), and all-cause mortality (22.4% vs 15.9%) were numerically higher in the CEA group, although these differences were not statistically significant. Subgroup analyses according to symptomatic status demonstrated no significant differences in 30-day, 1 or 3-year rates of stroke, MI, or all-cause mortality between the CEA and CAS groups.ConclusionIn this single-center experience, CAS achieved peri-procedural and short-term outcomes comparable to CEA, despite being performed in a more frail and comorbid patient population. These findings suggest that CAS may represent a safe and effective alternative to CEA in high-risk surgical candidates when performed by experienced operators within a multidisciplinary framework.

ObjectiveVascular closure devices (VCDs) are frequently employed to achieve hemostasis at the femoral puncture site, offering an alternative to traditional manual compression. However, a rare yet significant complication is common femoral artery (CFA) occlusion caused by suture-mediated VCDs. The optimal management of this complication remains unclear, with open surgical repair traditionally regarded as the standard of care. This paper aims to share our clinical experience in managing CFA occlusions caused by suture-mediated VCDs and to introduce our preferred endovascular treatment strategy.MethodsAt our institution, approximately 250 femoral artery hemostasis procedures using suture-mediated VCDs are performed annually. Over the past 10 years, we encountered 6 cases of CFA occlusion following the use of such devices. This corresponds to an incidence rate of approximately 0.24%. In all cases, endovascular management was selected as the primary treatment modality over open surgical intervention. Our endovascular approach consisted of initial balloon angioplasty, with adjunctive stenting performed when residual stenosis exceeded 50%.ResultsEndovascular treatment was technically successful in all 6 cases, with no major procedural complications. The mean degree of stenosis prior to balloon angioplasty was 91.9%, including 3 cases of long segmental occlusion. Balloon angioplasty alone was sufficient in 4 cases, while the remaining 2 required additional stenting to address significant residual stenosis. Final angiography demonstrated an average residual stenosis of 25.1%. During the follow-up period (mean duration: 37.8 months), no patients reported symptoms of lower extremity ischemia.ConclusionThis case series highlights the feasibility and efficacy of endovascular management as a first-line approach for CFA occlusion caused by suture-mediated VCDs. When diagnosis is delayed, long segmental occlusion with considerable thrombus burden may limit the effectiveness of balloon angioplasty alone, necessitating adjunctive stenting. Therefore, timely diagnosis and intervention are essential to optimize outcomes in these cases.

IntroductionBlunt trauma to the external iliac artery (EIA) is rare but potentially fatal. Endovascular stent-graft placement is used to control hemorrhage and restore limb perfusion. However, the safety profile and potential complications associated with stent-graft treatment are not well documented. We report a case of EIA injury following blunt trauma complicated by stent-graft deployment into a false lumen, successfully managed with an endovascular rescue technique.Case ReportAn 88-year-old man sustained blunt pelvic trauma with active extravasation from the left EIA. Initially, a covered stent-graft was deployed, which inadvertently caused arterial occlusion due to placement within a false lumen. A rescue procedure was performed using an endovascular approach, where a guidewire was advanced through the perigraft space and snared to establish a pull-through technique. Over this, a second stent-graft was deployed within the perigraft space, restoring flow through the true lumen. Follow-up computed tomography images confirmed successful recanalization and persistent exclusion of the false lumen.ConclusionThis case highlights the potential for stent-graft misplacement in EIA trauma and the importance of ensuring access to the true lumen. Accessing the perigraft space and placing an additional stent-graft represents a new therapeutic approach to achieve recanalization in similar complex vascular injuries.

BackgroundAortic dissection following endovascular aneurysm repair (EVAR) may be iatrogenic or a de-novo event. This study aims to systematically review all cases of dissection following EVAR to identify complications specific to each scenario and develop a management algorithm depending on the clinical presentation.MethodsA comprehensive literature search of MEDLINE, Embase, and CENTRAL databases was performed for all studies relating to dissection following EVAR or fenestrated/branched EVAR (F/BrEVAR). Data collected included timing (differentiating iatrogenic and de-novo events), entry tear location, endograft involved, complications, management, and subsequent outcomes. Due to limited data availability, descriptive data was collected and outcomes compared depending on dissection type and timing. Risk of bias was assessed using a standardised tool for case reports.Results46 patients in 37 studies were included. Complications included endograft compression (52.2%), endoleak (15.2%), and rupture (13.0%). Compression was less likely in endografts with proximal fixation (41.9%), compared to those without (69.2%). Type A dissection after EVAR required cardiac surgery with a high mortality (20.0%). In Type B dissection, 2 cases were diagnosed intra-operatively during F/BrEVAR, 1 died. 8 were diagnosed <4 weeks post-operatively, all managed medically with no complications or mortality. 31 were diagnosed >4 weeks, with mortality of 25.8% and high rates of endograft compression (58.1%), endoleak (16.1%), and rupture (19.4%).ConclusionAortic dissection following EVAR may cause endograft compression, endoleak, or rupture, with significant mortality. Complications are more frequent following Type A dissection and late Type B dissection. Early Type B dissection may be amenable to medical management.