Predicting features of visceral stent failure in fenestrated endovascular aortic aneurysm repair

Purpose: Visceral stents in fenestrated endovascular aortic repair (FEVAR) have a significant risk of complications and carry a considerable burden of reinterventions. The aim of this study is to identify preoperative and intraoperative predictors of visceral stent failure. Materials: A retrospective review of 75 consecutive FEVARs in a single center from 2013 to 2021 was undertaken. Data on mortality, stent failure, and reintervention pertaining to 226 visceral stents were collected. Methods: Anatomical features including aortic neck angulation, aneurysm diameter, and angulation of target viscerals were obtained from preoperative computed tomography (CT) scans. Stent oversizing and intraprocedural complications were recorded. Postoperative CT scans were analyzed to determine the length of cover of target vessels. Results: Only bridging stents through fenestrations to visceral vessels were considered; 28 (37%) cases had 4 visceral stents, 24 (32%) had 3, 19 (25%) had 2, 4 (5%) had 1. Thirty day mortality was 8%, a third of which was related to visceral stent complications. Intraprocedural complexity was documented during the cannulation of 8 (3.5%) target vessels, with a technical success rate of 98.7%. A significant endoleak or visceral stent failure was identified in 22 stents (9.8%) postoperatively, of which 7 (3%) had in-patient reintervention within 30 days. Further reinterventions at 1, 2, and 3 years were 12 (5.4%), 2 (1%), and 1 (0.4%), respectively. Most reinterventions were for renal stents (n=19, 86%). A smaller stent diameter and a shorter length of visceral stent were significant predictors of failure. No other anatomical feature or stent choice was found to be a significant predictor of failure. Conclusions: The modality of visceral stent failures varies, but renal stents with a smaller diameter and/or shorter length are more likely to fail over time. Their complications and reinterventions are common and carry a significant burden; therefore, close surveillance must be continued long term. Clinical impact: With this work we share the methodology adopted at our centre to treat juxtarenal aneurysm with FEVAR. Thanks to this detailed review of anatomical and technical features we provide guidance for endovascular surgeons to face hostile aneurysm with peculiar visceral vessels anatomy. With our findings will also motivate industries in their attempt to produce improved technologies able to overcome issues identified in this paper

Outcomes of patients with varicose veins

Introduction Varicose vein disease is a common ailment affecting the population. It is associated with causing an adverse effect on the quality of life of patients, with treatment of the condition known to improve it. The introduction of endovenous ablation has enabled the cost-effective treatment of the condition with procedures being carried out as day cases with an earlier return to normal activities. However, with healthcare expenditure increasingly under scrutiny, newer pathways are needed to continue the evolution of varicose vein management. Aim 1. To explore and compare the current and newer endovenous methods of treatment 2. To assess patients’ views of the current management of the condition 3. To evaluate a new referral and treatment pathway of varicose vein disease 4. To assess possible improvement in the post-procedural management of varicose veins Methods 1. A randomised controlled trial was conducted to compare radiofrequency ablation to mechanochemical ablation as well as a pilot study evaluating the use of a new cyanoacrylate adhesive sealing system. In addition, a systematic review and cost-effectiveness analysis was undertaken to evaluate the newer endovenous ablation methods. 2. A patient survey was carried out to understand the reasons for their referral as well as exploring a new management pathway. 3. A pilot study was undertaken to evaluate the feasibility of a One Stop Vein Clinic, offering same day diagnosis and treatment. 4. A randomised controlled trial comparing the use of compression stockings following endovenous ablation. Results 1. (a) With 170 patients recruited, the randomised controlled trial comparing radiofrequency and mechanochemical ablation shows that pain score during the procedure was less with the latter method, and that there were no other major differences between the two techniques. (b) This pilot study of 20 patients in the use of the new cyanoacrylate demonstrates that it is a safe and effective method, though a larger study would be able to provide further evidence of efficacy. (c) The systematic review shows that surgery and the endothermal methods seem to have lower re-intervention rates compared to foam sclerotherapy. However, a lack of comparative studies involving the non-thermal techniques meant that this analysis was unable to provide sufficient evidence as to their re-intervention rates and cost-effectiveness. 2. The patient survey of 106 patients revealed that they favoured less waiting time between appointments and their treatment. A high proportion of patients were also keen on attending a One Stop Clinic. 3. The early results of this pilot study of One Stop Vein Clinic shows that patients waited on average 4 weeks from being referred by their GP, but this study was hampered by unavailability of the treatment room for long periods and reduced possibility to add patients to the veins lists. 4. One hundred and nine patients have been recruited to the randomised controlled trial of the use of compression stockings. This shows that patients in the compression group had significantly less discomfort in the first few days following treatment, but there were no major differences by 2 weeks. Conclusions This work illustrates that varicose vein treatment is fast evolving. The newer technologies show promise, but currently, there is insufficient evidence to demonstrate their superiority over conventional endothermal methods. The One Stop Vein Clinic also shows potential, but may be difficult to incorporate into current practice without clear protocols between the different departments. The use of compression stockings following endothermal ablation indicates that it might be advantageous in the first few days, but may not necessarily have a long-term benefit.Open Acces

Appendices -Supplemental material for A systematic review of paediatric deep venous thrombolysis

<p>Supplemental material, Appendices for A systematic review of paediatric deep venous thrombolysis by Mohamed AH Taha, Andrew Busuttil, Roshan Bootun and Alun H Davies in Phlebology</p

Appendix 1 and 2 -Supplemental material for A systematic review on the use of deep venous stenting for acute venous thrombosis of the lower limb

<p>Supplemental material, Appendix 1 and 2 for A systematic review on the use of deep venous stenting for acute venous thrombosis of the lower limb by Mohamed AH Taha, Andrew Busuttil, Roshan Bootun and Alun H Davies in Phlebology</p