Emergent endovascular treatment options for thoracoabdominal aortic aneurysm

For a long time, parallel grafting, physician-modified endografts, and, more recently, in situ fenestration were the only go-to endovascular options for ruptured thoracoabdominal aortic aneurysm, offered mixed results, and depended mainly on the operator's and center's experience. As custom-made devices have become an established endovascular treatment option for elective thoracoabdominal aortic aneurysm, they are not a viable option in the emergency setting, as endograft production can take up to 4 months. The development of off-the-shelf (OTS) multibranched devices with a standardized configuration has allowed the treatment of ruptured thoracoabdominal aortic aneurysm with emergent branched endovascular procedures. The Zenith t-Branch device (Cook Medical) was the first readily available graft outside the United States to receive the CE mark (in 2012) and is currently the most studied device for those indications. A new device, the E-nside thoracoabdominal branch endoprosthesis OTS multibranched endograft (Artivion), has been made commercially available, and the GORE EXCLUDER thoracoabdominal branch endoprosthesis OTS multibranched endograft (W. L. Gore and Associates) is expected to be released in 2023. Due to the lack of guidelines on ruptured thoracoabdominal aortic aneurysm, this review summarizes the available treatment options (ie, parallel grafts, physician-modified endografts, in situ fenestrations, and OTS multibranched devices), compares the indications and contraindications, and points out the evidence gaps that should be filled in the next decade

Primary Absence of Type II Endoleak is A Positive Prognostic Factor against the Risk of Late Conversion of EVAR for AAA

Introduction: The aim of this study is to analyze 12 late conversion to open surgery after Endovascular Repair of Abdominal Aortic Aneurysms (EVAR) while comparing the follow up of these cases to that of the definitely successful procedures (absence of surgical conversion, type I or III endoleaks, or presence of type II endoleaks without any aneurysmal sac enlargement) . Methods: From a series of over 300 EVAR procedures performed at our department we have selected 215 cases with a follow up ≥ 6 month and primary technical success (successful deployment of the devices and discharge of patients without neither type I nor III endoleaks). Based on the final data recorded at the end of the follow up (mean+ IQR: 38.16 months + 41), these cases were divided into three groups: group 1, with 12 cases (5.6%) which needed surgical conversion in a later stage (5 to 55 months from EVAR); group 2, with 39 cases (18.1%) with type II endoleaks without aneurysmal sac enlargement; group 3, with 164 cases (76.5%) without endoleaks. The groups were compared in relation to the following parameters: a) personal data and common atherogenic risk factor, b) diameter of the aneurysm, c) kind of the proximal fixation of the endograft (suprarenal or infrarenal), d) presence of endoleaks at the first postoperative check. We have compared the data from the three groups and we have analyzed them with chi-square test (Χ2). Results: Personal data and common atherogenic risk factor have proved no significant difference among the three groups. The incidence of the other three parameters of group 1 was compared with the incidence of these in groups 2 and 3: the mean pre-operative diameter of the aneurysm results 51 mm in group 1, 54 mm in group 2 and 55 mm in group 3 (not significant); suprarenal fixation of the prosthesis accounts for 50% in group 1, 51% in group 2 and 60% in group 3 (not significant); presence of type II endoleak at the first post-operative check was 41.6% in group 1, 56.4% in group 2 (not significant) and 9.7% in group 3 (p<0.001, compared to groups 1 and 2). Conclusion: In the EVAR procedures with primary technical success, the absence of type II endoleak at the first post-operative check represents a favorable prognostic factor against the risk of late conversion to open repair. Personal data, common atherogenic risk factor, diameter of the aneurysm and fixing type of the prosthesis don’t seem to influence the onset of this complication

A drastic complex atheromatous aorta. A case report

Aortic atherosclerosis is the most common disease of the aorta. More than 50% of the plaques thicker than 4 mm are located along the descending aorta. The complex morphology of the plaque, such as ulceration or the presence of thrombi, is associated with increased embolic risk. The increasing use of transesophageal echocardiogram has enhanced the recognition of aortic atheromas. We describe a case of a male patient with complex atherosclerotic disease involving the coronary vessels and descending aortic tract with some embolic complications

Helsinki-Vantaan lentoaseman tilannekuvakeskus : Häiriö- ja poikkeamatilanteiden eteneminen lentoasemalla

Tämän opinnäytetyön tavoitteena oli selvittää, miten Finavian ylläpitämällä Helsinki-Vantaa lentoasemalla tapahtuvat häiriö- ja poikkeamatilanteet vaikuttavat lentoasemalla toimiviin Finavian omiin organisaatioihin sekä lentoasemalla toimiviin viranomaisiin. Häiriö- ja poikkeamatilanteella tarkoitetaan lentoaseman normaaliin toimintaan häiritsevästi vaikuttavaa tapahtumaa, esimerkiksi sähkökatkoa. Työ tehtiin Helsinki-Vantaa lentoaseman tilannekuvakeskuksen päällikön pyynnöstä. Tilannekuvakeskuksessa huomattiin, että vaikka häiriö- ja poikkeamatilanteessa toiminta eri tahojen kanssa on ollut kitkatonta ja sujuvaa, ei toisen organisaation sisällä tapahtuvasta toiminnasta ollut kuvaa. Työn avulla selvitettiin, onko häiriö- tai poikkeamatilanteella vaikutusta eri organisaatioiden ja viranomaisten toimintaan. Opinnäytetyö auttaa rakentamaan kokonaiskäsitystä poikkeamatilanteiden aiheuttamasta toiminnasta koko lentoaseman alueella. Tätä kautta voidaan myös lisätä ymmärrystä eri organisaatioiden ja viranomaisten välillä. Opinnäytetyö toteutettiin yhteistyössä Helsinki-Vantaa lentoaseman tilannekuvakeskuksen kanssa. Työn edetessä rakennetta muokattiin yhteistyössä tilaajan kanssa niin, että se palvelisi mahdollisimman tarkoituksenmukaisesti eri organisaatioita. Työ toteutettiin tekemällä laadullinen tutkimus, jonka runkona oli puolistrukturoitu haastattelu. Haastatteluita kertyi yhteensä 19 kappaletta ja haastateltavia 21. Haastateltavina olivat Finavian eri organisaatioiden johtajia tai päälliköitä ja lentoaseman toimintaan liittyvien viranomaisten lentoaseman toimipisteiden päälliköt. Työstä rajattiin pois kaupalliset yritykset, koska haastatteluiden määrä olisi kasvanut liian suureksi. Lentoaseman tilannekuvakeskus on luonut useita valmiita toimintamalleja erilaisiin häiriö- ja poikkeamatilanteisiin. Tilannekuvakeskuksen päällikkö valitsi näistä häiriö- ja poikkeamatilanteista ne, jotka ovat todennäköisiä tai merkittäviä ja vaikuttavat haitallisesti lentoaseman toimintaan. Erilaisia häiriö- ja poikkeamatilanteita valikoitui 17 kappaletta. Näiden tilanteiden vaikutuksia ja toimintamalleja käsiteltiin haastatteluissa. Haastatteluissa saatu informaatio liitettiin tilannekuvakeskuksen toimintamalleihin ja luotiin jokaiseen valittuun poikkeamatilanteeseen kronologinen kuvaus eri organisaatioiden toiminnasta. Opinnäytetyöstä on myöhemmin tarkoitus tehdä pelkistetympi käsikirja Finavian ja viranomaisten käyttöön.The aim of this study was to find out how to Finavia’s Helsinki-Vantaa airport take place in crisis and emergency situations and how they affecting operating at the airport Finavia's own organizations as well as authorities operating at the airport. The work was done at the request of the Head of the Helsinki-Vantaa airport operation center. The airport operation center noted that although the crisis and emergency situations operation with various parties has been smooth, but nobody didn’t have a picture how these crisis and emergency situations was handled in the another organizations. The work purpose was to find out whether the fault or deviation situation could affect the functioning of the various organizations and public authorities. The thesis helps to build the overall understanding of the actions caused by the deviation of situations throughout the airport. This period may also increase the understanding of the different organizations and authorities. The research was conducted in cooperation with the Helsinki-Vantaa airport operation center. As work progresses, the structure was modified in cooperation with the client so that it would serve as appropriately as possible the different organizations. The work was carried out by qualitative research, whose backbone was the semi-structured interview. Interviews were a total of 19 tracks and 21 interviewees were interviewed leaders or managers in different organizations and Finavia's airport activities related to airport authorities, heads of offices. Work were excluded trading companies, because the number of interviews had grown too large. The airport operation center has created a number of ready-made models for different crisis and emergency situations. Head of the Centre chose a snapshot of the crisis and emergency situations, those who are likely or significant and adversely affect the operation of the airport. 17 various types of crisis and emergency situations was selected. Effects and models of these situations addressed in the interviews. The information obtained in the interviews attached a airport operation center’s operational models and was created for each selected deviation situation chronological description of the activities of various organizations. The thesis is later to be made simpler manual for use by Finavia and the authorities

Referral from vascular surgery to cardiovascular rehabilitation and related outcomes in patients with peripheral arterial disease: the THINKPAD-RELOADED survey.

The utilization of cardiovascular rehabilitation (CR) programmes in patients with Lower Extremity Peripheral Artery Disease (LEPAD) is generally poor, with limited evidence of current policies for referral. The aim of the study was to evaluate, within a cohesive network of CR and vascular surgery facilities with facilitated referral process, the clinical characteristic of LEPAD patients referred to CR and related outcomes, as compared to patients not referred. The present is an observational prospective study of consecutive patients recruited at vascular surgery facilities. Out of 329 patients observed, the average referral rate to CR was 34% (28% and 39% in patients with and without recent peripheral revascularization, p<0.05). LEPAD patients entering the CR programme were similar to those who did not according to sex, age, the vascular surgery setting of evaluation, and localization of arterial lesions. Patients with moderate intermittent claudication and patients with acute limb ischemia as index event were more represented among those who attended CR (41% vs 21% and 9% vs 2% respectively, p<0.05). Patients referred to CR had five times more episodes of acute coronary syndrome and heart failure as complication of the index event. The cardiovascular risk profile (obesity 29.5% vs 11%, p<0.05; hypercholesterolemia 80% vs 61%, p<0.05) was much worse in LEPAD patients referred to CR, but conversely, they better achieved secondary prevention targets, particularly for blood pressure control (97% vs 57%, p<0.05). All-cause 2-year mortality in the whole patients' population was 6%. Patients entering the CR programme displayed less events (13.5% vs 37.7%, p<0.05), mainly death (3.1% vs 11.3%, p<0.05) and limb-related events (4.2% vs 15.2%, p<0.05). The results of our study suggest that when a cohesive network of vascular surgery and CR facilities becomes available, the referral rate to rehabilitation may increase up to one third of eligible patients. Patients with higher comorbidity and cardiovascular risk seem to have priority in the referral process, nevertheless those with peripheral revascularization are still underestimated. Entering CR may ensure better cardiovascular risk profile and cardiovascular prognosis in LEPAD patients, and consequently the systematic adoption of this care model needs to be strongly recommended and facilitated

Upper arm AVF Is it always the first choice?

Population aging, demographic changes, treatment improvement and the consequent lengthening of patient life-expectancy force physicians to face new challenges, in this exciting new era of vascular accesses. The purpose is still to extend the survival of the vascular access as much as possible, trying to preserve the vascular pathway, ensuring a good dialysis quality, even in the most challenging cases as well as in emergency. Current technology and new materials are leading this revolution. The present book is intended to be a pragmatic resource to be consulted quickly in the commonest clinical situations. For this reason, the book consists of short chapters, developed by points, with clear and direct explanations. it has been written by authors all over the word, that decided to share their own personal experience as well as the most recent trials and result