Endovascular treatment of large and wide aortic neck: case report and literature review

Large (24\u201334 mm) and wide ( 6535 mm) aortic necks are a contraindication to endovascular aneurysm repair (EVAR). A 63-year-old man, unfit for conventional surgery, presented a 79 mm abdominal aortic aneurysm with 36.5 mm aortic neck and a 62 mm right common iliac artery aneurysm. He was treated endovascularly with standard commercially available stent-graft using the so-called \u2018funnel technique\u2019; by placing a thoracic stent-graft inside a bifurcated device to achieve proximal sealing. The completion angiography and the 6 months follow-up with computed tomography showed no stent-graft migration, limb occlusion or endoleak. The literature review reported 179 cases of large aortic neck managed with EVAR, all cases treated with standard devices. Conversely a wide aortic neck was reported in 9; in 2 cases were employed custom-made devices and in 7 standard stent-graft. The use of EVAR with commercially available stent-grafts is feasible and it represents an option especially in non-elective setting

Inflammatory Abdominal Aortic Aneurysm (IAAA)

Purpose: The aim of this study is to report our experience about the inflammatory abdominal aortic aneurysm (IAAA). Methods: Between January 1999 and January 2008 we treated 8 cases of IAAA. Two patients underwent surgery in emergency. The preoperative diagnostic procedures were ultrasound (US), computed tomography (CT) and intravenous urography (IVU). In 6 elective patients the diagnosis of IAAA was obtained preoperatively. In one case a left hydroureteronephrosis was demonstrated by intravenous urography (IVU). All patients underwent open surgery with midline incision and transperitoneal access. Results: No 30-days mortality occurred. A case of pancreatitis was treated with conservative therapy. All patients had 60-days corticosteroid therapy. Conclusions: Our data suggest that because IAAA have the same rate of rupture of AAA, they need the same preventive treatment as non inflammatory abdominal aortic aneurysm (AAA) The kind of approach OPEN-EVAR should be chosen with the same criteria as AAA, even if EVAR teatment doesn't allow us to obtain the biopsy. Furthermore there are no sufficient evidences about regression of retroperitoneal fibrosis after EVAR treatment. Also the premature onset should be considered in the choice of treatment

Carotid artery stenting with contralateral carotid occlusion in a rare aortic arch configuration

We present the case of a 47-year-old man admitted to our department with an episode of aphasia. Duplex scan showed an occluded right internal carotid artery and severe left internal carotid artery stenosis. Contrast-enhanced computer tomography demonstrated a common trunk for both common carotid arteries anterior to the trachea and aberrant right subclavian artery posterior to the esophagus. The patient was considered to be a high risk for carotid endarterectomy and, consequently, we performed stenting of the left carotid artery. To our knowledge, this is the first case reporting the combination of these two aortic arch anomalies and the concomitant endovascular treatment of atherosclerotic carotid stenosis

Streamlining models with explanations in the learning loop

Several explainable AI methods allow a Machine Learning user to get insights on the classification process of a black-box model in the form of local linear explanations. With such information, the user can judge which features are locally relevant for the classification outcome, and get an understanding of how the model reasons. Standard supervised learning processes are purely driven by the original features and target labels, without any feedback loop informed by the local relevance of the features identified by the post-hoc explanations. In this paper, we exploit this newly obtained information to design a feature engineering phase, where we combine explanations with feature values. To do so, we develop two different strategies, named Iterative Dataset Weighting and Targeted Replacement Values, which generate streamlined models that better mimic the explanation process presented to the user. We show how these streamlined models compare to the original black-box classifiers, in terms of accuracy and compactness of the newly produced explanations.Comment: 16 pages, 10 figures, available repositor

Clinical outcomes of endurant II stent-graft for infrarenal aortic aneurysm repair: Comparison of on-label versus off-label use

PURPOSE We aimed to compare the outcomes of the Endurant II (Medtronic) stent-graft used under instructions for use versus off-label in high-risk patients considered unfit for conventional surgery. METHODS Data from patients treated with the Endurant II stent-graft between December 2012 and March 2015 were retrospectively analyzed. Sixty-four patients were included. Patients were assigned to group A if treated under instructions for use (n=34, 53%) and to group B if treated off-label (n=30, 47%). Outcome measures included perioperative mortality and morbidity, survival, freedom from reintervention, endoleak incidence, in-hospital length of stay, and mean stent-graft component used. Mean follow-up was 22.61±12 months (median, 21.06 months; range, 0–43 months). RESULTS One perioperative mortality (1.6%) and one perioperative complication (1.6%) occurred in group B. At two months follow-up, one iliac limb occlusion (1.6%) occurred in group A. No type I/III endoleaks were recorded. A type II endoleak was identified in three cases (4.7%). Overall survival at three years was 89% (97% for group A, 82% for group B; P = 0.428). Reintervention-free survival at three years was 97% for both groups (P = 0.991). A longer in-hospital stay was observed in group B (P = 0.012). CONCLUSION The Endurant II (Medtronic) new generation device was safe in off-label setting at mid-term follow-up. The off-label use of the Endurant II (Medtronic) is justified in patients considered unfit for conventional surgery. Larger studies are required in this subgroup of patients

Type 1A endoleak detachable coil embolization after endovascular aneurysm sealing: Case report

Introduction: Endovascular aneurysm sealing (EVAS) with the Nellix system was introduced to reduce endovascular aneurysm repair (EVAR) perioperative complications, especially endoleaks. Herein we report a case of successful type 1A endoleak managed with detachable coils embolization after EVAS. Presentation of case: A 77-year-old male was referred for abdominal pain. The angio-CT scan confirmed the previous EVAS procedure and showed a type Is2 endoleak below the right renal artery resulting in a 2.5 cm aortic blister with contrast medium filling the space between the aortic wall and the endobags. The patient was considered unfit for conventional open surgery and an endovascular approach with coil embolization Concerto Helix Detachable Coil System was chosen under local anesthesia. After intervention, a complete abdominal pain regression was registered. The 12- month CT follow-up showed endoleak sealing and Nellix system stability. Discussion: EVAS has been associated to a high endoleaks and complications incidence when compared to EVAR. The EVAS different device concept led to a different endoleak classification and management. Endoleak management main options include the Nellix system explantation or the Nellix in Nellix application, however these are nearly always not applicable, respectively, due to the high surgical risk condition and the Nellix system availability, especially in emergent setting. Despite the use of coil embolization is controversial, this tool is off-the-shelf and leads to a disease resolution in most of patients without other surgical options. Conclusion: Proximal type Is2 embolization after EVAS is feasible with limited invasiveness

Late Complication after Superficial Femoral Artery (SFA) Aneurysm: Stent-graft Expulsion Outside the Skin

A 78-year-old man presented with a 7-cm aneurysm in the left superficial femoral artery, which was considered unfit and anatomically unsuitable for conven- tional open surgery for multiple comorbidities. The patient was treated with stent-graft [Viabhan stent-graft (WL Gore and Associates, Flagstaff, AZ)]. Two years from stent-graft implantation, the patient presented a purulent secretion and a spontaneous external expulsion through a fistulous channel. No claudication symptoms or hemorrhagic signs were present. The pus and device cultures were positive for Staphylococcus aureus sensitive to piperacillin/tazobac- tam. Patient management consisted of fistula drainage, systemic antibiotic therapy, and daily wound dressing. At 1-month follow-up, the wound was closed. To our knowl- edge, this is the first case of this type of stent-graft com- plication presenting with external expulsion

Multilevel diabetic foot revascularization in COVID 19 patient: Case report

Introduction: Coronavirus 2019 (COVID-19) has been associated with endothelial dysfunction. This hypercoagulable state coming from the endothelial injury pones COVID-19 patients to a higher risk for thrombosis. COVID 19 diabetic patients are more exposed to peripheral vascular disease progression. Multilevel peripheral arterial disease is the main cause of critical limb ischemia. Vascular interventions are required to increase distal blood flow and reduce the risk of amputation. Presentation of case: We report a case of complex revascularization in a diabetic patient with aggressive right foot lesions evolution after COVID-19 infection. The patient presenting a Peripheral arterial ischemic involving the infrarenal aorta, iliac, femoral. The simultaneous intervention consisted of an endovascular aortic stent-graft placement and angioplasty of femoral artery. Discussion: Diabetes is a risk factor of severity and deaths in patients infected with pulmonary viruses. In our experience, COVID 19 virus can accelerate the ulcers generation and progression in diabetic patient. Hybrid interventions can be performed simultaneously or staged with benefit given by the complementary role of endovascular and surgical treatments. In the reported case, a complex simultaneous treatment in a patient presenting Multilevel peripheral arterial disease in association to COVID 19 infection was feasible in the same operation. Conclusion: Hybrid procedures are safe with high degree of efficacy in terms of revascularization, reduced morbidity and shorter intensive care. In our experience, the use of a hybrid procedure is technically feasible and allowed the treatment of complicated diabetic COVID-19 patient with a good outcome

Endograft connector technique to treat popliteal artery aneurysm in a morbid obese patient.

Surgical repair of popliteal artery aneurysm in morbid obese patients poses additional challenges. We report a morbid obese patient who had a 59mm right popliteal artery aneurysm which was successfully treated with the endograft connector technique. This technique was used to perform the distal anastomosis of the below-knee femoro-popliteal bypass. A 10mm Dacron graft was used as a main graft bypass and an 11 mm/10 cm stentgraft as endograft connector. Following the respective tunnel of the Dacron graft, an end-to-side proximal anastomosis was performed at distal femoral artery. The aneurysm exclusion was obtained through a proximal and a distal ligation. Postoperative duplex showed adequate bypass patency. Knee x-rays demonstrated no signs of stent kinking/fractures. The postoperative course was uneventful and the patient was discharged home on fourth day post operative. The six-month computed tomography scan and the 12-month duplex control showed a patent bypass with no signs of stenosis