Intentional coverage of the left subclavian artery during endovascular repair of traumatic descending thoracic aortic transection

ObjectiveThis single-center, prospective study aimed to investigate the technical success and outcome of intentional coverage of the left subclavian artery (LSA) in patients undergoing thoracic endovascular aortic repair (TEVAR) for traumatic rupture of the aortic isthmus at a tertiary care medical center.MethodsFrom January 2005 to June 2011, patients who presented with traumatic aortic transection underwent TEVAR with coverage of the LSA when the distance between the artery and the rupture was <2 cm. At 12, 24, and 72 hours postoperatively, clinical and neurologic evaluation including transcranial Doppler insonation of the brachial artery was performed. A decrease in peak systolic velocity (PSV) >60% with respect to the contralateral one was considered relevant. Functional status of the left arm was evaluated using a provocative test. Thoracoabdominal computerized tomographic angiography was performed postoperatively at 3-, 6-, and 12-month follow-up.ResultsThirty-one patients (mean age 35 years) underwent emergency TEVAR for traumatic aortic transection with intentional LSA coverage during the study period. In four cases (12.9%) coverage was partial. Two patients (6.4%) died during the postoperative period due to associated lesions. No signs of vertebrobasilar insufficiency, stroke, or paraplegia were observed in any of the patients. Nine patients (36%) had severe arm claudication (ischemic pain within 60 seconds of beginning arm exercise and decrease of PSV between 50% and 60%). Risk factors for the condition were left vertebral artery diameter <3 mm (P < .0001). A significant correlation was found between the degree of PSV reduction and left arm symptoms (P < .0001). There was an improvement in ischemic arm symptoms (P < .0001) during mean follow-up of 36 months (range, 6-65 months), with only one patient (4.2%) presenting with severe claudication. Freedom from reintervention at 48 months was 93.5%. No signs of endoleaks or graft migrations were detected on computerized tomographic angiography control scans.ConclusionsCoverage of the LSA during TEVAR for traumatic aortic injuries appears to be a feasible, safe method for extending the endograft landing zone without increasing the risk of paraplegia, stroke, or left arm ischemia. Left vertebral artery diameter can be used to identify patients at risk for postoperative left arm ischemia

The Primary patency in endovascular treatment of femoropopliteal lesions with Eluvia Paclitaxel-Eluting Stent: single-centre experience.

Restenosis of the obstructive lesions in the superficial femoral or proximal popliteal artery, treated with angioplasty or bare nitinol stenting, frequently occurs. Paclitaxel-eluting stents have been developed to protect against restenosis with the sustained antiproliferative agent release over time. The aim of this study was to report the results about the primary patency in a cohort of patients with long and complex femoropopliteal lesions treated with the Eluvia Drug-Eluting Vascular Stent. The single-center, retrospective, single-arm, study enrolled 61 patients with chronic, symptomatic or asymptomatic, lower limb ischemia and stenotic or occlusive lesions in the superficial femoral artery or proximal popliteal artery. Mean lesion length was 129,3 ± 88,6. Efficacy measures at 18 months included primary patency, defined as duplex ultrasound peak systolic velocity ratio of ≤2.4 and the absence of target lesion revascularization or bypass. The Kaplan–Meier estimate of primary patency through 18 months was on average 83% and precisely 87.5% for patients TASC II A, 91% for patients TASC II B, 83% for patients TASC II C and 73% for patients TASC II D. Six months after the initial procedure primary patency was on average 91,5% and precisely 87.5% for patients TASC II A, 91% for patients TASC II B, 89,5% for patients TASC II C and 100% for patients TASC II D. No stent fractures were identified, and no major target limb amputations occurred. This study confirmed the efficacy of he paclitaxel-eluting Eluvia stent to treat long and complex femoropopliteal lesions

Clamping ischemia, threshold ischemia and delayed insertion of the shunt during carotid endarterectomy with patch

JCR ISI 2001 I.F. 0.55Abstract BACKGROUND: Shunt insertion during carotid endarterectomy (CEA) is mandatory to avoid neurological damage due to clamping ischemia; however shunt insertion before plaque removal has many inconveniences (atheroembolism, intimal dissection, difficulty of endarterectomy). The aim of this study is to verify whether and how long shunt insertion may be safely delayed to permit plaque removal and ensure cerebral perfusion during the further time consuming manoeuvres of CEA (peeling, patch angioplasty). METHODS: From July 1990 to February 1996 383 patients underwent 411 CEAs under general anesthesia with EEG continuous monitoring and PTFE patch angioplasty. A Pruitt-Inahara shunt was routinely inserted only after atherosclerotic plaque removal. In 316 CEAs (76.9%) without EEG signs of cerebral ischemia (Group A) the mean clamping time was 10 min +/-4.8 (range 2-37 min). In 95 CEAs (23.1%) with EEG signs of cerebral ischemia (Group B) it was 7.3 min +/-3.5 (range 3-20 min). All patients had normal EEG signals after delayed shunt insertion and reperfusion (mean 21 min, range 5-45 min). RESULTS: In the short term results (within 30 days) there was a relevant neurological complication rate of 0.96% (2 major stroke and 2 lethal stroke); at awakening we observed 5 RINDs (1.21% of total) 1 in a patient of Group A (0.31%) and the other 4 in patients of Group B (4.21%). CONCLUSIONS: These data confirm the rationale of a delayed insertion of the shunt: actually the cerebral parenchyma may tolerate under general anesthesia a sufferance due to carotid clamping, EEG detectable, without neurological deficits for at least 7.3 min. This time is sufficient to perform the most difficult steps of CEA (plaque removal, distal intima checking) allowing shunt insertion in a clean operatory field, without inconveniences. Finally the shunt allows complementary time consuming steps, as patch angioplasty, with improvement of both short- and long-term results

Endovascular treatment of asymptomatic popliteal aneurysms: 8-year concurrent comparison with open repair

7nonenoneAntonello M; Frigatti P; Battocchio P; Lepidi S; Dall'antonia A; Deriu GP; Grego FAntonello, M; Frigatti, P; Battocchio, P; Lepidi, S; Dall'Antonia, A; Deriu, Gp; Grego,

Role of aneurysm sac embolization during endovascular aneurysm repair in the prevention of type II endoleak-related complications

ObjectiveThe goal of this study was to evaluate the role of intraoperative aneurysm sac embolization during endovascular aneurysm repair (EVAR) using a standard dose of coils and fibrin glue in the prevention of type II endoleak (EII).MethodsTwo groups were compared: 83 patients underwent standard EVAR during the period 2008-2009 (group A) and 79 patients underwent EVAR during the period 2010-2011 (group B). Computed tomography scans were evaluated with Osirix Pro 4.0 software to obtain aneurysm sac volume. EII rates at the first computed tomography scan follow-up, as well as midterm freedom from EII and freedom from related reintervention, were compared. Preoperative number of patent aortic side branches (inferior mesenteric artery, lumbar arteries, accessory renal arteries), sac thrombus, and sac volume were evaluated for their association with EII in the two groups using multiple logistic regressions.ResultsPatient characteristics, Society for Vascular Surgery comorbidity scores (0.85 ± 0.44 vs 0.82 ± 0.46; P = .96), and operative time (185 ± 52 vs 179 ± 49; P = .92) were similar for groups A and B. The first computed tomography scan (≤3 months) revealed a significantly larger number of EIIs in group A than in group B (23% vs 10%; P = .02). Spontaneous EII resolution occurred in 65% of patients in group A and in 79% in group B (P = 1.0), whereas sac volume increased in 25% and 10% (P = .63) of cases, respectively. At 18 months (range, 6 months to 4.4 years), overall mean differences in sac volume shrinkage (27 ± 12 cm3 vs 25 ± 12 cm3; P = .19) and freedom from EII (92% vs 96%; P = .33) were similar, whereas freedom from reintervention was significantly lower in group A (93% vs 99%; P = .03) than in group B. Multivariate analysis showed preoperative aneurysm sac volume >125 cm3 to be the only independent significant predictor of EII (odds ratio, 4.0; 95% confidence interval, 1.5-10.5; P = .005).ConclusionsAlthough further confirmatory studies are needed, sac embolization during EVAR may be a valid approach to preventing EII and its complications during short- and midterm follow-up. More aggressive intraoperative embolization should be considered for patients with a preoperative aneurysm sac volume >125 cm3