Ultrasound guided full mechanical thrombectomy of a floating thrombus in the common femoral vein

A Floating Venous Thrombus (FVT) in the deep venous system has a high potential to cause pulmonary embolization. There are no defined criteria for treatments described in the literature, which range from anticoagulation and fibrinolytic treatments, through open or endovascular thrombectomies, to more invasive procedures such as surgical interruption with ligation of the venous system. Catheter-directed thrombolysis is effective for treatment of venous clots, but it is associated with increased risk of bleeding. Mechanical thrombectomy currently represents a valid therapeutic option without the need for lytic therapy and with excellent short and medium-term results. We herein present a technical note through an explicative case of a patient with an FVT located in the left common femoral vein who underwent to percutaneous venous mechanical thrombectomy (ClotTriever, Inari Medical, Irvine, CA, USA) under ultrasound guidance without an intravascular ultrasound check. At the end of the treatment, venography and duplex ultrasound scan showed ilio-femoral patency without residual thrombus. No further procedures were needed and the patient was discharged two days post-intervention with oral anticoagulation and compression therapy with stockings

High Risk of Secondary Infections Following Thrombotic Complications in Patients With COVID-19

Background. This study’s primary aim was to evaluate the impact of thrombotic complications on the development of secondary infections. The secondary aim was to compare the etiology of secondary infections in patients with and without thrombotic complications. Methods. This was a cohort study (NCT04318366) of coronavirus disease 2019 (COVID-19) patients hospitalized at IRCCS San Raffaele Hospital between February 25 and June 30, 2020. Incidence rates (IRs) were calculated by univariable Poisson regression as the number of cases per 1000 person-days of follow-up (PDFU) with 95% confidence intervals. The cumulative incidence functions of secondary infections according to thrombotic complications were compared with Gray’s method accounting for competing risk of death. A multivariable Fine-Gray model was applied to assess factors associated with risk of secondary infections. Results. Overall, 109/904 patients had 176 secondary infections (IR, 10.0; 95% CI, 8.8–11.5; per 1000-PDFU). The IRs of secondary infections among patients with or without thrombotic complications were 15.0 (95% CI, 10.7–21.0) and 9.3 (95% CI, 7.9–11.0) per 1000-PDFU, respectively (P = .017). At multivariable analysis, thrombotic complications were associated with the development of secondary infections (subdistribution hazard ratio, 1.788; 95% CI, 1.018–3.140; P = .043). The etiology of secondary infections was similar in patients with and without thrombotic complications. Conclusions. In patients with COVID-19, thrombotic complications were associated with a high risk of secondary infections

Comparison of Open and Endovascular Surgery for the Treatment of the Infections of the Thoracic Aorta

Objectives: The purpose of the study was to compare the results of open and endovascular treatment for the infections of the thoracic aorta. Materials and Methods: Between 1993 and 2015, 1516 patients were treated in our institution for diseases of the thoracic and thoraco-abdominal aorta, including 49 for infection at the thoracic level. Twenty-six primitive mycotic aneurysms, 13 cases of infected thoracic aortic grafts and 10 cases of infected thoracic stentgrafts were operated. In this group a fistula with the esophagus and/or the bronchial tree was observed in 24 cases (49%). Results: In the group of the patients treated for mycotic aneurysm, 16 (61%) had an open surgical treatment with the replacement of the thoracic aorta with a silver impregnated prosthesis. In this group five procedures associated an esophageal repair and one pulmonary lobectomy were necessary. Peroperative mortality was 19% (three patients). The other ten patients (39%) were treated with ndovascular treatment (TEVAR) with antibiotic impregnated stentgrafts. In this group technical success was 100% in absence of perioperative deaths. After an average follow-up of 84\ub120 months, mortality was 25% (four patients) after open treatment (25%) and 10% after TEVAR (one patient). In the group of the prosthetic infections open surgical treatment was carried out in 17 patients with 11 procedures of associated visceral repair. TEVAR was carried out in six cases with a procedure of associated visceral repair. Perioperative mortality after open treatment was 30% (n\ubc5); no perioperative death was observed after TEVAR. After a follow-up of 61\ub128 months, mortality was 53% and 50% after open surgery and TEVAR, respectively; the rate of reintervention was 6% after open surgery and 33% after TEVAR. Conclusion: The infections of the thoracic aorta present a very high mortality in the event of fistula with the esophagus and/or the bronchial tree requiring an associated surgical treatment. In our series TEVAR gave a higher survival rate for the treatment of primitive mycotic aneurysms than for the infections of surgical grafts or of stentgrafts. In the event of prosthetic infection TEVAR was associated with a higher rate of reintervention

Distal Embolization and Proximal Stent-Graft Deployment: A Dual Approach to Endovascular Treatment of Ruptured Superior Gluteal Artery Aneurysm

Aneurysmal disease of the hypogastric branches is rare; it may be life-threatening, and the treatment is often challenging. Herein, we report the case of an 81-year-old man with arterial hypertension, obesity, renal insufficiency, and psychiatric disorders who was emergently admitted for a symptomatic ruptured aneurysm of a hypogastric arterial branch, as seen on magnetic resonance angiography. Endovascular treatment was performed by means of a dual approach: distal embolization with microspheres and Gianturco coils, followed by proximal complete exclusion via deployment of a stent-graft in the common iliac artery. The outcome was favorable, with complete exclusion of the aneurysm and normalization of renal function

Late retrograde migration of a left subclavian artery chimney stent-graft into the innominate artery

Purpose: To report an uncommon case of chimney stent-graft migration in the aortic arch. Case Report: A 29-year-old man presented with chronic left arm hyposthenia after late displacement and thrombosis of a left subclavian artery (LSA) chimney graft that migrated retrogradely into the innominate artery 2 years after deployment. The self-expanding LSA chimney was placed during a redo procedure to repair a pseudoaneurysm and type I endoleak after an index emergency thoracic endovascular aortic repair for traumatic aortic rupture 1 year earlier. The patient was successfully treated in an elective procedure via a median sternotomy, with arch aortotomy under circulatory arrest to remove the proximal end of the thrombosed chimney graft from the ostium of the innominate trunk. Three months later, a left carotid-to-subclavian bypass was performed to restore flow to the left arm. Conclusion: Migration of the proximal end of an overly long chimney graft that moved freely in the aortic arch exposed the patient to a high risk of stroke and death. Because of the high-risk situation, open repair under circulatory arrest was elected to remove the proximal end of the chimney graft, with no major complications

Comparison of sacrificed healthy aorta during thoracoabdominal aortic aneurysm repair using off-the-shelf endovascular branched devices and open surgery

Off-the-shelf devices for branched endovascular aortic repair of thoracoabdominal aortic aneurysm (TAAA) have been developed to overcome the manufacturing- and logistics-related delays characteristic of device customization. Nonetheless, the structural requirements of branched endovascular aortic repair, together with the need for additional thoracic components to suit different anatomies, might lead to a large sacrifice of healthy aorta

Propensity-matched comparison for carotid artery stenting in primary stenosis versus post-CEA restenosis

Objectives Carotid artery stenting (CAS) has been proposed as the treatment of choice in case of post-carotid endarterectomy (CEA) restenosis. The aim of the study is to analyze periprocedural results of CAS for the treatment of post-CEA restenosis (RES) compared with those of CAS performed for primary carotid stenosis (PRS). Methods Data from consecutive patients submitted to CAS at our Institution from 2008 to 2016 were retrospectively reviewed. Patients with in-stent restenosis were excluded. Initially, preoperative risk factors, demographics, intraoperative variables and perioperative outcome were analyzed according to indication group (PRS and RES). Then, propensity score matching was performed obtaining two homogeneous groups of patients. Covariates included were: age, gender, hypertension, hyperlipidemia, cardiac disease, chronic renal disease, symptomatic carotid plaque and positive ipsilateral brain CT-scan. Intraoperative data and perioperative outcomes were then compared between the two matched groups. Results Of 480 included patients, 300 (62.5%) underwent CAS for PRS, and 180 (37.5%) for RES. After propensity score analysis (158 patients per group), no significant difference were observed in terms of technical success, number and type of stent used, except for need of intraoperative atropine administration that was higher in PRS group (38.6% vs 13.3%, respectively; p<.001). In the perioperative period, the composite neurological event was significantly higher in PRS group (7.6% vs 1.9%; p=.017). Moreover, need of ionotropic support was higher in PRS group (8.9% vs 1,9%; p=.0069). Myocardial infarction rate and 30-day mortality were similar in the two groups (p=.317; p=1, respectively). Conclusions In a large single-center experience, CAS for post-CEA restenosis was associated with a significantly lower risk of any neurological event and of hemodynamic instability in the perioperative period as compared to CAS performed for primary carotid lesions. Our results confirm that post-CEA restenosis may represent an elective indication for CAS

Late surgical conversion of failed Multilayer Flow Modulator stenting in thoraco-abdominal aneurysms

The aim of this study was to report the outcomes of open or hybrid repair of failed thoraco-abdominal aortic aneurysm endovascular treatment with Multilayer Flow Modulator (MFM) stents

Open or endovascular treatment of downstream thoracic or thoraco-abdominal aortic pathology after frozen elephant trunk: perioperative and mid-term outcomes

 : Objectives: The aim of this study was to evaluate the outcomes of open and endovascular treatment of downstream thoracic or thoraco-abdominal aortic pathology in patients who underwent previous frozen elephant trunk (FET). Methods: Data were retrieved to evaluate mortality, cardiac, pulmonary, cerebrovascular, renal and spinal cord major adverse events, early- and mid-term reintervention and survival rates. The Society for Vascular Surgery endovascular reporting standards were used. Results: From 2011 to 2020, 48 patients (36 males, median age 60 years) underwent downstream aortic repair at a median of 18 months (interquartile range: 6-57) after the initial FET. Twenty-eight patients (58.3%) received open and 20 (41.7%) endovascular repair. The overall 30-day mortality was 6.3% and the initial clinical success was 88%, with no inter-group differences (P = 0.22 and 0.66 respectively). Six spinal cord deficits were recorded (13%): 3 (6.3%) were permanent. The major adverse events incidence was lower in the endovascular cohort [4 (20%) vs 14 (50%); P = 0.047], mainly due to a lower rate of grade ≥2 respiratory complications (5% vs 42.9%; P = 0.004). Assisted primary clinical success at 5 years was higher in the endovascular group (95% vs 68%, P = 0.022); freedom from reintervention at competing risk analysis (P = 0.3) and overall survival at Kaplan-Meier curves (log-rank P = 0.29) were similar. Conclusions: Downstream aortic repair after FET is feasible with both open and endovascular repair with acceptable mortality and permanent paraplegia rates. The endovascular approach has potential perioperative and mid-term advantages, but long-term durability has to be further investigated in larger cohorts