Rivascolarizzazioni Infra-Poplitee Complesse in pazienti con Ischemia Critica degli Arti Inferiori: esperienza dell’ Unita’ Vascolare del St. Thomas’ Hospital

Introduzione: L’incidenza della Ischemia Critica degli Arti Inferiori (CLI) e’ costantemente in crescita nella popolazione mondiale. Sia i bypass che le procedure endovascolari infra-poplitee hanno dimostrato simili risultati, tuttavia non sono ancora disponibili i risultati di trial randomizzati che possano indirizzare verso la miglior scelta di trattamento. Materiali e Metodi: E’ stato analizzato un database di pazienti affetti da CLI e sottoposti ad angioplastica infra-poplitea presso il St Thomas’ Hospital tra 2012-2014. 1. Identificazione dei “predittori di outcome clinici a medio termine” nelle rivascolarizzazioni endovascolari infra-poplitee nei pazienti affetti da CLI Risultati: sono stati tratti 393 target vessels in 201 arti inferiori . Ad 1 e 2 anni, AFS e’ stata 77% e 55%, F-MALE 72% e 64%. Il successo tecnico per arto inferiore e’ stato 94% I tassi di pervieta’ primaria, assistita e secondaria sono stati 67%, 72%, 76% ad 1 anno. La Regressione Multivariata ha identificato la terapia doppio antiaggregante quali predittori indipendenti di AFS(P=.034) e MALE(P=.002). L’eta’ giovanile (P <.001) e eGFR (P=.009) sono correlabili con una miglior AFS. Conclusioni: La AFS e’ significativamente peggiore nei pazienti anziani ed in coloro con bassi valori di eGFR; al contrario una adeguata terapia doppio antiaggregante post-procedurale e’ un predittore favorevole di miglior AFS e F-MALE. 2. Il ruolo dell'approccio integrato multidisciplinare nella rivascolarizzazione infra-poplitea nei pazienti anziani ottuagenari e nonagenari affetti da CLI Risultati: Un totale di 129 arti inferiori in 120 pazienti sono stati rivascolarizzati mediante bypass infra-popliteo(n=42) e trattamento endovasculare(n=87); l’eta’ media di 85(±5) anni. AFS di 71%-68% nel sottogruppo sottoposto a bypass e 53%-21% nel sottogruppo endovascolare(P<0.001). Il tasso di mortalita’ perioperatoria complessiva e’ stato 2%. OS 68% and 54% ad 1 e 2 anni. Diabete(P=.046) e bassa eGFR(P=.041) sono stati identificati quali predittori negativi di AFS e OS. Conclusioni: La rivascolarizzazione infra-poplitea e’ possibile ed efficace nei pazienti anziani ottuagenari e nonagenari con CLI. La “sub-group analysis” suggerisce che i bypass chirugici possano avere una migliore pervieta’ secondaria a medio termine e migliori tassi di AFS. 3. Analisi comparativa tra i bypass distali e le rivascolarizzazioni endovascolari tibiali nei pazienti con CLI infra-poplitea mediante Propensity Score Analysis Risultati: I due sottogruppi iniziali (complessivamente n=279) differivano per incidenza di diabete(P=.024), eGFR(P=.006), lunghezza della lesione (P<.001) e per classificazione clinica(P=.008). Tali fattori confondenti sono stati usati per construire il modello di PS raggiungendo una coorte omogenea di 125 in ciascun sottogruppo. La pervieta’ primaria(P=0.014), assistita(P=0.003), secondaria(P<0.001) e l’ AFS(P=.043) sono risultate migliori nei BS. Il salvataggio d’arto e’ stato simile(P=.161), mentre la ospedalizzazione(P=0.001) piu’ lunga nel gruppo BS. Conclusioni: I nostri dati sono a sostengo di un approccio pragmatico nel quale i pazienti che dispongano di una adeguata vena safena e con accettabile rischio operatorio sono indirizzati verso il bypass chirurgico 4. Angioplastiche di salvataggio nei bypass infra-poplitei a rischio: impatto sulla pervieta’ e sulla Amputation Free Survival Risultati: Un totale di 122 bypass infra-poplitei sono stati realizzati in 108 pazienti. La pervieta’ primaria, assistita e secondaria e’ stata 56%,73%,81% a 12mesi e 44%, 68%,78% a 24mesi. AFS 79% a 12mesi e 73% a 24mesi. Le angioplastiche sono state eseguite su 61(50%) bypass. AFS e’ risulata simile nei bypass “a rischio” e “non a rischio”(P=0.064) Conclusioni: I re-interventi endovascolari secondari nei bypass distali “a rischio” sono efficaci e permettono di mantenere la pervieta’ del graft, con una migliore AFS ed un basso tasso di complicanze.THESIS OVERVIEW Peripheral arterial disease (PAD) is the third leading cause of atherosclerotic cardiovascular morbidity, following coronary artery disease and stroke. In the 21st century, PAD has become a pandemic problem carrying significant healthcare, social and economic implications. The prevalence of PAD is exponentially increasing, affecting over 200 million people worldwide (Nogren et al. (TASC II), J Vasc Surg 207). Despite more than two-third of PAD patients being concentrated in low-middle income countries, over 61 million people are estimated to be affected by the disease in wealthy nations; the incidence of PAD has increased globally by 23·5% in the last decade, with an estimated increased prevalence of up to 50% in the elderly population of high-income countries, due to the longer life expectancy (Fowkes et al. Lancet 2013). Angiographic evidence of infra-popliteal disease, involving the tibial vessels, has been shown in approximately two third of the population with Critical Limb Ischaemia (CLI), requiring in most cases endovascular or surgical limb-salvage revascularisation (Bradbury et al. J Vas Surg 2010). The management of distal (infra-popliteal) atheromatous disease remains a clinical and technical challenge, affecting a higher risk population burdened by more severe co-morbidities when compared to more proximal disease. Despite many centres and guidelines recommending an endovascular-first strategy for infra-popliteal CLI, there is a paucity of scientific evidence to support the choice of treatment, with both bypass surgery and endovascular treatment showing relatively good outcomes. Two randomised controlled trials, the BASIL 3 and BEST-CLI, comparing the endovascular treatment versus bypass surgery, are still ongoing and their preliminary findings not being expected to be published anytime soon. Surprisingly, an extensive analysis of the US Medicare population (Vogel et al. J Vasc Surg 2011) has shown an increased incidence of severe in-hospital complications after angioplasty, rather than after bypass surgery, in the elderly population. The scope of this study was to conduct a retrospective analysis of a prospectively maintained database of consecutive CLI patients undergoing infra-popliteal endovascular and surgical revascularisation at a single institution, St Thomas’ Hospital Vascular Unit. This thesis is built on four sequential chapters to follow the outlined clinical research pathway: Chapter 1 Analyses a large contemporary cohort of consecutive CLI patients undergoing infra-popliteal endovascular treatment (angioplasty) with a view of identifying the predictors of clinical outcome (Amputation Free Survival - AFS and Freedom from Major Adverse Limb Events - F-MALE). Chapter 2 Provides a cohort subanalysis of the elderly patients (octogenarians and nonagenarians) comparing the clinical outcome following infrapopliteal endovascular treatment versus bypass surgery. The importance of the peri-operative management (Comprehensive Geriatric Assessment - CGA) provided by the POPS team to improve survival and functional outcome has been emphasised. Chapter 3 Compares the outcomes of bypass surgery and endovascular treatment in the whole cohort of CLI patients with infra-popliteal disease by using a Propensity Score Analysis. This statistical approach allows a strong level of evidence, correcting for selection bias and confounding factors. Awaiting for randomised controlled trials to publish their preliminary findings, statistical methods such as regression and propensity score models offer the best way to draw meaningful, evidence based conclusions to direct the treatment decision making. Chapter 4 Examines the role of endovascular salvage angioplasty to maintain distal (infra-popliteal) bypass graft primary-assisted and secondary patency. The frequency of such interventions and the overall clinical outcomes (limb salvage and AFS) have been analysed

Usefulness of new imaging methods for assessment of type B aortic dissection

While the medical management of uncomplicated type B aortic dissection has good outcomes in the short term, the longer term mortality can be in the region of 50% at 5 years. Up to 40% of the survivors can have significant dilatation of the false lumen with the risk of aneurysm formation and death due to rupture. The results of the randomized controlled trials ADSORB and INSTEAD-XL have shown that beneficial aortic remodelling occurs after endoluminal stent graft placement, but these trials were underpowered to show any effect on survival. Static computed tomography (CT) angiography imaging methods have been used to try to identify high risk patients using parameters such as diameter, the position and size of the entry tear, and the amount of false lumen thrombus, but these so far are not able to clinically risk stratify individual patients. In this manuscript, we present our initial experience with new MR imaging methods. These have allowed us to develop a greater understanding of aortic dissection by providing information regarding the underlying hemodynamic and biomechanics of the dissection, as well as more accurate assessment of important clinical imaging endpoints, such as false lumen thrombosis

Superior Mesenteric Artery Aneurysm Caused by Aortic Valve Endocarditis: The Case Report and Review of the Literature

Infectious aneurysms of the superior mesenteric artery are a rare but life-threatening condition due to the risk of visceral ischemia, sepsis, or hemorrhage. In this study, we report the case of a superior mesenteric artery aneurysm (SMAA) secondary to a bioprosthetic valve endocarditis, successfully managed with aneurysm resection and saphenous vein interposition graft. We performed an extensive PubMed-based rewiew of the literature of the last 10 years on SMAA, which include the detection of 38 articles quoting 41 SMAAs. The case histories were divided in 2 groups: 18 cases belonged to nonmycotic group A and 23 cases were included in mycotic group B. In group A, 44.4% of patients were treated surgically, whereas in group B, 90.5%. The 2 study groups significantly differed (P =.01) in terms of surgical treatment. The surgical approach still remains the first choice of treatment in mycotic aneurysm

Supervised Exercise Therapy and Revascularization for Intermittent Claudication Network Meta-Analysis of Randomized Controlled Trials

Objectives: The aim of this study was to perform a comprehensive meta-analysis comparing all therapeutic modalities for intermittent claudication (IC), including best medical therapy (BMT) alone, percutaneous angioplasty (PTA), supervised exercise therapy (SET), and PTA combined with SET, to establish the optimal first-line treatment for IC. Background: IC is a common health problem that limits physical activity, results in decreased quality of life (QoL) and is associated with poor cardiovascular outcomes. Previous meta-analyses have attempted to combine data from randomized trials; however, none have combined data from all possible treatment combinations or synthesized QoL outcomes. Methods: Following a systematic review of the published research (conducted in December 2018) that identified 37 published randomized trials, a network meta-analysis was performed combining all possible IC treatment strategies. Results: Overall, 2,983 patients with IC were included (mean weighted age 68 years, 54.5% men). Comparisons were performed between BMT (n = 688, 28 arms) versus SET (n = 1,189, 35 arms) versus PTA (n = 511, 12 arms) versus PTA plus SET (n = 395, 8 arms). Mean weighted follow-up was 12 months (95% confidence interval: 9 to 23 months). Compared with BMT alone, PTA plus SET outperformed other treatment strategies, with a maximum walking distance gain of 290 m (95% credible interval: 180 to 390 m; p < 0.001). A variety of QoL assessments using validated tools were reported in 15 trials; PTA plus SET was superior to other treatments (Cohen's D = 1.8; 95% credible interval: 0.21 to 3.4). Conclusions: In addition to BMT, PTA combined with SET seems to be the optimal first-line treatment strategy for IC in terms of maximum walking distance and QoL improvement