A double nellix and chimney covered stents: challenging treatment of pararenal aortic aneurysm

A 77-year-old male patient presented with a symptomatic, 66-mm pararenal aortic aneurysm. The patient was classified as unsuitable for open surgery due to significant comorbidities. Fenestrated or branched endografts were contraindicated due to the poor iliac access (6 mm diameter). A double Nellix with chimney endovascular aneurysm sealing (ChEVAS) technique was selected to exclude the pararenal aortic aneurysm and to preserve renal arteries and the superior mesenteric artery. Technical preplanning considered the ideal proximal landing zone to be close to the origin of the almost occluded celiac trunk and the distal common iliac arteries as the ideal distal landing zone. The total length of the aorta to cover was estimated as >180 mm, requiring 2 aortic EVAS systems, bilaterally overlapped. Technical success was achieved, and the patient was discharged on postoperative day 8 in good general condition. Successful aneurysm exclusion and target vessel patency without endoleak or stent-graft kinking or migration were confirmed at angio-computed tomography at 6 months

Morphofunctional characterization of a rare extracranial internal carotid artery giant aneurism

Aneurisms of the extracranial tract of the internal carotid artery (EICAA) are extremely rare, accounting for 0,4% to 2% of all carotid procedures (El-Sabrout et al., 2000); in females incidence is 2-11 times lower than in males (Siablis et al., 2004). A giant EICAA (32 x 35 mm) at C3 level was studied in a woman aged 81. Samples were prepared for standard transmission electron microscopy. Semithin sections were stained according to Relucenti et al. (2010). Ultrathin sections were contrasted with uranyl acetate and lead citrate. Images revealed the presence of many microvessels just beneath the tunica intima. They were patent, often showed sprouts and pericytes. Endothelial cells appeared metabolically active, with euchromatin, nucleoli, membrane blebs and junctional complexes. Their basal membrane was thickened and sometimes multilaminated. Leukocytes adhering to the endothelium were observed. The internal elastic lamina was so fragmented that it was very difficult to recognize it. The tunica media showed vascular smooth muscle cells (VSMCs) arranged in bundles encircled by collagen-rich extracellular matrix (EM), as well as scattered in the EM. VSMCs had perinuclear organelles, dense bands and caveolae. Collagen fibrils were arranged in a twisted or coiled fashion. Elongated fibroblasts were scattered among VSMCs. The external elastic lamina was conserved. Literature on EICAA is almost exclusively clinical, so this morphofunctional study elucidates structural and ultrastructural changes in the aneurism wall that can contribute to the knowledge of aneurism etiopathogenesis

The role of the profundoplasty in the modern management of patient with peripheral vascular disease

BACKGROUND: The occlusion of superficial femoris artery (SFA) is a common feature in peripheral vascular disease, so the profunda femoris artery (PFA) is a crucial collateral pathway for the perfusion of the lower limb. The purpose of this study is to discuss the safety, clinical, and hemodynamic efficacy of profundoplasty on the basis of limb salvage, patency, and freedom from reintervention rates. Furthermore, this study aims to identify the risk factors linked to the failure of the procedure. METHODS: The study is based on a retrospective analysis of prospectively collected data of identified patients who underwent profundoplasty from March 2005 to October 2015. All patients showed a hemodynamic stenosis, extended from the posterior wall of the common femoral artery (CFA) into the origin of the PFA and concomitant occlusion of SFA. Endarterectomy with patch angioplasty was performed in all cases. In patients with concomitant iliac occlusive disease, a hybrid treatment was carried out to restore an adequate inflow through an endovascular approach. RESULTS: Seventy-four profundoplasty were performed during the study period. Isolate profundoplasty was performed in 56 cases (75.7%), while in the remaining 18 cases (24.3%), concomitant endovascular treatment of iliac lesions was performed. Hemodynamic success was achieved in 90.5% of the cases. The mean ankle-brachial index significantly improved, rising from 0.36 ± 0.17 preoperatively to 0.57 ± 0.20 postoperatively (P < 0.001). The median follow-up period was 33 months. Primary patency rate was 98.5% at 12, 36, and 60 months. Freedom from reintervention rate was 97% at 1 year and 95.3% at 3 and 5 years. Limb salvage rate was 96.9% at 1 year and 92.7% at 3 and 5 years. Survival rates were 86%, 60%, and 47.4% at 1, 3, and 5 years, respectively. Multivariate analysis identified Rutherford class 5 or 6 lesions as the strongest predictors of major amputation or reintervention (odds ratio, 9.37; confidence interval: 0.98-89.27; P = 0.05). CONCLUSIONS: Profundoplasty is a durable, safe, and effective procedure in terms of clinical and hemodynamic results for patients characterized by occlusion of SFA and stenosis of CFA extended to profunda ostium. For patients with Rutherford category 5 and 6 ischemia, the only profundoplasty does not seem to be adequate, and concomitant distal bypass should be necessary to improve limb salvage and decrease reintervention rate

Hemodynamic changes in chevalier eversion versus conventional carotid endarterectomy

Objectives The eversion carotid endartectomy (E-CEA), mainly performed by means of Vanmaele technique, has been associated with loss of the baroreceptor reflex and postoperative hypertension. The purpose of this paper is to determine whether the eversion endarterectomy performed by means of Chevalier technique (C-CEA) modifies the function and the efficiency of baroreceptors, leading to lower postoperative hemodynamic change. Methods A retrospective review of 380 patients who underwent carotid endarterectomy (120 Chevalier-CEA; 260 Standard-CEA) from December 2002 to November 2012 has been performed. The changes of blood pressure baseline during the postoperative course in C-CEA and S-CEA group were analysed and compared. Postoperative hypertension was defined as an elevation of systolic pressure >180 mm Hg or >40% rise above baseline. Results The patients with Chevalier eversion technique did not develop a significantly higher blood pressure in the postoperative course compared to those operated with the standard technique. In the recovery room, the mean systolic blood pressure was 134 ± 21.9 mm Hg in C-CEA group versus 132 ± 24.6 mm Hg in S-CEA group. In the first postoperative day it was 132 ± 17.2 mm Hg in C-CEA versus 133 ± 17.4 mm Hg in S-CEA group. During the first six hours in the recovery room, the need for intravenous antihypertensive drugs was similar in the two groups. Fourteen patients in C-CEA group (11%) and thirty patients (11.5%) in the S-CEA group required vasodilators, without any significant difference (p = 1). The dosage of current preoperative antihypertensive therapy was increased in six patients (4.9%) of C-CEA group and in twelve patients (4.9%) of S-CEA group, without significant difference (p = 1). Conclusions C-CEA has the same rate of postoperative hypertension of standard-CEA, which is probably related to the sparing of baroreceptor apparatus, compared to standard E-CEA. The Chevalier procedure could represent an E-CEA technique with its inherent advantages, without penalties related to postoperative hypertension, commonly observed after E-CEA

Hypothermia during Carotid Endarterectomy: A Safety Study.

CEA is associated with peri-operative risk of brain ischemia, due both to emboli production caused by manipulation of the plaque and to potentially noxious reduction of cerebral blood flow by carotid clamping. Mild hypothermia (34-35°C) is probably the most effective approach to protect brain from ischemic insult. It is therefore a substantial hypothesis that hypothermia lowers the risk of ischemic brain damage potentially associated with CEA. Purpose of the study is to test whether systemic endovascular cooling to a target of 34.5-35°C, initiated before and maintained during CEA, is feasible and safe.The study was carried out in 7 consecutive patients referred to the Vascular Surgery Unit and judged eligible for CEA. Cooling was initiated 60-90 min before CEA, by endovascular approach (Zoll system). The target temperature was maintained during CEA, followed by passive, controlled rewarming (0.4°C/h). The whole procedure was carried out under anesthesia.All the patients enrolled had no adverse events. Two patients exhibited a transient bradycardia (heart rate 30 beats/min). There were no significant differences in the clinical status, laboratory and physiological data measured before and after CEA.Systemic cooling to 34.5-35.0°C, initiated before and maintained during carotid clamping, is feasible and safe.ClinicalTrials.gov NCT02629653

Morphofunctional characterization of a rare extracranial carotid artery giant aneurism

Aneurisms of the extracranial tract of the internal carotid artery (EICAA) are extremely rare, accounting for 0,4% to 2% of all carotid procedures (El-Sabrout et al., 2000); in females incidence is 2-11 times lower than in males (Siablis et al., 2004). A giant EICAA (32 x 35 mm) at C3 level was studied in a woman aged 81. Samples were prepared for standard transmission electron microscopy. Semithin sections were stained according to Relucenti et al. (2010). Ultrathin sections were contrasted with uranyl acetate and lead citrate. Images revealed the presence of many microvessels just beneath the tunica intima. They were patent, often showed sprouts and pericytes. Endothelial cells appeared metabolically active, with euchromatin, nucleoli, membrane blebs and junctional complexes. Their basal membrane was thickened and sometimes multilaminated. Leukocytes adhering to the endothelium were observed. The internal elastic lamina was so fragmented that it was very difficult to recognize it. The tunica media showed vascular smooth muscle cells (VSMCs) arranged in bundles encircled by collagen-rich extracellular matrix (EM), as well as scattered in the EM. VSMCs had perinuclear organelles, dense bands and caveolae. Collagen fibrils were arranged in a twisted or coiled fashion. Elongated fibroblasts were scattered among VSMCs. The external elastic lamina was conserved. Literature on EICAA is almost exclusively clinical, so this morphofunctional study elucidates structural and ultrastructural changes in the aneurism wall that can contribute to the knowledge of aneurism etiopathogenesis