Towards an entirely endovascular aortic world: an update of techniques and outcomes for endovascular and open treatment of type I, II, and III endoleaks

Endovascular aneurysm repair (EVAR) is largely the most adopted strategy for aneurysmal disease of the aorta. Nevertheless, the high incidence of reintervention makes it difficult to identify EVAR as a definitive solution; in particular, the most frequent indication of reintervention is endoleak, which is defined as persistent flow into the aneurysmal sac from different sources. Several treatment strategies are described. A contemporary literature search was performed with the intent of describing techniques and outcomes of endovascular and open strategies to type I, II, and III endoleak. Described techniques and outcomes were organized by indication (type I, II, and III endoleak) and by type of approach (endovascular, open, and laparoscopic) to give an overview of the current status of the treatment for the three most frequent types of endoleak. Several endovascular means are described in the literature for the treatment of endoleak

"Over-SIRIX". A new method for sizing aortic endografts in combination with the chimney grafts. early experience with aortic arch disease

Abstract BACKGROUND: Large gutters after chimney procedures are one of the main causes of type I endoleak (EL-I). This study aims to evaluate a new tailored planning named "Over-SIRIX," based on Osirix Imaging Software, to choose the correct main graft oversizing in order to minimize EL-I incidence. METHODS: From 2008 to 2015, 34 patients were treated with parallel grafts for aortic arch diseases at our institution. The study included 22 patients with single stent and antegrade flow configuration; they were divided into 2 groups (PRE- and POST-"Over-SIRIX"). "Over-SIRIX" was carried out in the retrospective group (PRE-"Over-SIRIX"), and it was used to plan the endovascular procedure in the prospective group (POST-"Over-SIRIX"). Through the multiplanar reconstruction (MPR) of the preoperative computed tomography angiography (CTA), the proximal neck of the chimney grafts was studied. Stent and endograft configurations were drawn in order to minimize the "gutters." To obtain the ideal main graft sizing (I-Size), a formula was used by adding the custom sizing (C-Size) to the disease oversizing (D-Over). The same MPR imaging was evaluated on postoperative CTA to study gutters area and presence of EL-I. RESULTS: The mean I-Size was 41.67 mm that was equivalent to an ideal oversizing of 19.3% (range 10-28%). The gutters area decreased from 7.3 to 1.7 mm2 (PRE/POST) and EL-I rate from 28.5% to 0% (PRE/POST). Gutters area bigger than 7.5 mm2 and planning made without "Over-SIRIX" were significantly associated (P < 0.05) to EL-I. CONCLUSIONS: "Over-SIRIX" appears to be a feasible method to customize planning during chimney technique, reducing the risk of EL-I which is significantly related to the presence and size of the gutters

Surgical treatment of thoracic outlet syndrome: immediate and mid-term results

Introduction: We report the results from a consecutive series of patients treated by scalenectomy or cervical rib resection for clearly symptomatic or paucisymptomatic thoracic outlet syndrome (TOS) over a 6-year period. Material and methods: From September 1999 to August 2005, 14 surgical decompressions were performed in 12 patients with unremitting signs and symptoms of nerve or vascular compression at the thoracic outlet. The symptoms of TOS were due to involvement of the brachial plexus in 8 cases (57.1%). A sign of vascular obstruction could be detected in 10 cases (71.4%): in 6 cases (42.8%) the presentation was predominantly arterial (arm claudication, coldness, Raynaud’s phenomenon and distal embolisation) and in 4 cases (28.5%) was related to vein compression with congestion and swelling of the affected arm or vein thrombosis. Two patients presented as emergencies with critical upper limb ischaemia or distal vessel embolisation. Results: The median follow-up period was 28.2 months (range 8-78 months). Results were evaluated in terms of technical success, lack of complications (temporary or permanent plexus injury, temporary or permanent phrenic palsy), relief of symptoms. Outcome data were divided into immediate/perioperative and mid-term results. Perioperative results: There was no operative mortality. Technical success was achieved in all patients in excision of the fibrous band with scalenectomy and in cervical rib excision. Mid-term results: In 4 patients with venous symptoms complete relief was achieved in 75%. In all patients who experienced arterial complications we registered complete relief. In patients with neurological presentation we detected complete relief in 5 (62.5%), relief of some symptoms in 2 (25%) and no improvement in 1 (12.5%). Conclusions: Scalenectomy performed by a standard supraclavicular approach seems to allow relief in the majority of patients with symptoms of neurological, arterial or venous compression at the thoracic outlet. Nevertheless, we emphasize the importance of an objective method of evaluation and the necessity of a prolonged follow-up. Key words: thoracic outlet syndrome, scalenectomy, cervical rib resection

IL TRATTAMENTO ENDOVASCOLARE DELL’ANEURISMA DELL’AORTA ADDOMINALE: NOSTRA ESPERIENZA ENDOVASCULAR TREATMENT OF ABDOMINAL AORTIC ANEURISMS: OUR EXPERIENCE

Background. This report prospectively analyzes collected data of endovascular treatment of abdominal aortic aneurysms in 114 patients selected to receive stent implantation based on anatomic criteria and surgical risk. Methods. From December 2002 to May 2006, 114 patients with abdominal aortic aneurism receive endovascular treatment. 108 were men (94,7%) and 6 female; age range was 57-86 years with mean age of 73.3. The mean maximum diameter of the AAA was 5.71 cm (range 3.7- 13.0). Three different types of stents were used most of which were bifurcated in design (97,3%). Endograft used were: Excluder, Talent; Zenith-Cook. Results. No perioperative mortality was observed; 5 (4,3%) type I and 11 (9,6%) type II endoleak were detected; Iliac extension with exclusion of the internal iliac artery was required in 27 cases. We observed 2 right branch, 2 iliac lesions, 2 ematoma and 1 distal vessels embolization surgically treated Mean follow-up period was 18,6 months. 17 patients died during follow-up. 11 endoleak were discovered during follow-up and in 3 cases thrombosis of a branch occurred. Mean aneurysm diameter, neck diameter, iliac or hypogastric diameter or the clinical characteristics showed no statistical significant differences among the three group (on the results). In each group influence of aneurysm and neck morphology and diameter on type I or II endoleak was analyzed but no statistical significant differences were detected among the three groups except for type-II endoleak in the Talent group that was registered in 100% of no mural thrombus – aneurysms (p<0,05). Conclusions. Together with aneurysm sac growth andbranch vessels’ patency, structural failures continues to be a challenging problem. As long as no solution will be find out for them endovascular aneurysm repair will remain an imperfect long-term treatment and continued follow-up will be mandatory. Key words: Aortic aneurysm, Aortic surgery, Endovascular treatment

1-Year results from a prospective experience on CAS using the CGuard stent system: The IRONGUARD 2 study

Objectives: The aim of this study was to evaluate the 1-year safety and efficacy of a dual-layered stent (DLS) for carotid artery stenting (CAS) in a multicenter registry. Background: DLS have been proved to be safe and efficient during short-term follow-up. Recent data have raised the concern that the benefit of CAS performed with using a DLS may be hampered by a higher restenosis rate at 1 year. Methods: From January 2017 to June 2019, a physician-initiated, prospective, multispecialty registry enrolled 733 consecutive patients undergoing CAS using the CGuard embolic prevention system at 20 centers. The primary endpoint was the occurrence of death and stroke at 1 year. Secondary endpoints were 1-year rates of transient ischemic attack, acute myocardial infarction, internal carotid artery (ICA) restenosis, in-stent thrombosis, and external carotid artery occlusion. Results: At 1 year, follow-up was available in 726 patients (99.04%). Beyond 30 days postprocedure, 1 minor stroke (0.13%), four transient ischemic attacks (0.55%), 2 fatal acute myocardial infarctions (0.27%), and 6 noncardiac deaths (1.10%) occurred. On duplex ultrasound examination, ICA restenosis was found in 6 patients (0.82%): 2 total occlusions and 4 in-stent restenoses. No predictors of target ICA restenosis and/or occlusion could be detected, and dual-antiplatelet therapy duration (90 days vs 30 days) was not found to be related to major adverse cardiovascular event or restenosis occurrence. Conclusions: This real-world registry suggests that DLS use in clinical practice is safe and associated with minimal occurrence of adverse neurologic events up to 12-month follow-up

Insight from an Italian Delphi Consensus on EVAR feasibility outside the instruction for use: the SAFE EVAR Study

Background: The SAfety and FEasibility of standard EVAR outside the instruction for use (SAFE-EVAR) Study was designed to define the attitude of Italian vascular surgeons towards the use of standard endovascular repair (EVAR) for infrarenal abdominal aortic aneurysm (AAA) outside the instruction for use (IFU) through a Delphi consensus endorsed by the Italian Society of Vascular and Endovascular Surgery (Società Italiana di Chirurgia Vascolare ed Endovascolare - SICVE). Methods: A questionnaire consisting of 26 statements was developed, validated by an 18-member Advisory Board, and then sent to 600 Italian vascular surgeons. The Delphi process was structured in three subsequent rounds which took place between April and June 2023. In the first two rounds, respondents could indicate one of the following five degrees of agreement: 1) strongly agree; 2) partially agree; 3) neither agree nor disagree; 4) partially disagree; 5) strongly disagree; while in the third round only three different choices were proposed: 1) agree; 2) neither agree nor disagree; 3) disagree. We considered the consensus reached when ≥70% of respondents agreed on one of the options. After the conclusion of each round, a report describing the percentage distribution of the answers was sent to all the participants. Results: Two-hundred-forty-four (40.6%) Italian Vascular Surgeons agreed to participate the first round of the Delphi Consensus; the second and the third rounds of the Delphi collected 230 responders (94.3% of the first-round responders). Four statements (15.4%) reached a consensus in the first rounds. Among the 22 remaining statements, one more consensus (3.8%) was achieved in the second round. Finally, seven more statements (26.9%) reached a consensus in the simplified last round. Globally, a consensus was reached for almost half of the proposed statements (46.1%). Conclusions: The relatively low consensus rate obtained in this Delphi seems to confirm the discrepancy between Guideline recommendations and daily clinical practice. The data collected could represent the source for a possible guidelines' revision and the proposal of specific Good Practice Points in all those aspects with only little evidence available

Second asymptomatic carotid surgery trial (ACST-2) : a randomised comparison of carotid artery stenting versus carotid endarterectomy

Background: Among asymptomatic patients with severe carotid artery stenosis but no recent stroke or transient cerebral ischaemia, either carotid artery stenting (CAS) or carotid endarterectomy (CEA) can restore patency and reduce long-term stroke risks. However, from recent national registry data, each option causes about 1% procedural risk of disabling stroke or death. Comparison of their long-term protective effects requires large-scale randomised evidence. Methods: ACST-2 is an international multicentre randomised trial of CAS versus CEA among asymptomatic patients with severe stenosis thought to require intervention, interpreted with all other relevant trials. Patients were eligible if they had severe unilateral or bilateral carotid artery stenosis and both doctor and patient agreed that a carotid procedure should be undertaken, but they were substantially uncertain which one to choose. Patients were randomly allocated to CAS or CEA and followed up at 1 month and then annually, for a mean 5 years. Procedural events were those within 30 days of the intervention. Intention-to-treat analyses are provided. Analyses including procedural hazards use tabular methods. Analyses and meta-analyses of non-procedural strokes use Kaplan-Meier and log-rank methods. The trial is registered with the ISRCTN registry, ISRCTN21144362. Findings: Between Jan 15, 2008, and Dec 31, 2020, 3625 patients in 130 centres were randomly allocated, 1811 to CAS and 1814 to CEA, with good compliance, good medical therapy and a mean 5 years of follow-up. Overall, 1% had disabling stroke or death procedurally (15 allocated to CAS and 18 to CEA) and 2% had non-disabling procedural stroke (48 allocated to CAS and 29 to CEA). Kaplan-Meier estimates of 5-year non-procedural stroke were 2·5% in each group for fatal or disabling stroke, and 5·3% with CAS versus 4·5% with CEA for any stroke (rate ratio [RR] 1·16, 95% CI 0·86-1·57; p=0·33). Combining RRs for any non-procedural stroke in all CAS versus CEA trials, the RR was similar in symptomatic and asymptomatic patients (overall RR 1·11, 95% CI 0·91-1·32; p=0·21). Interpretation: Serious complications are similarly uncommon after competent CAS and CEA, and the long-term effects of these two carotid artery procedures on fatal or disabling stroke are comparable