Nellix endovascular aortic sealing endoprosthesis late explantation for concomitant type I endoleak and stent frames proximal caudal migration

Endovascular aneurysm sealing (EVAS) using the Nellix™ System was introduced in clinical practice with the aim of reducing the incidence of complications such as migration, endoleaks, and reinterventions after conventional endovascular aneurysm repair (EVAR). Although, initial efficacy data on this device have been encouraging, EVAS has also demonstrated to undergo adverse events. Herein, we report a case of Nellix graft explant due to endobags shrinkage after air bubble reabsorption leading to proximal type I A endoleak and stent migration. The focus of this article is on the importance of a more assiduous surveillance of this new device, in particular in those cases with air into the endobags immediately after the procedure; this surveillance should be aimed to timely identify complications which can otherwise lead to consequences that require open conversion

Outcomes in the emergency endovascular repair of blunt thoracic aortic injuries

Abstract Thoracic aorta blunt injury (BAI) is a highly lethal lesion. A large number of victims die before obtaining emergency care. Thoracic endovascular aneurysm repair (TEVAR) is a less invasive method compared with open surgery and may change protocols for BAI treatment. This retrospective study was developed to evaluate the potential issues about thoracic endografting in the management of these patients. Twenty-seven patients with a BAI underwent aortic stent grafting. Intervention was preceded by the treatment of more urgent associated lesions in nine cases. In-hospital mortality was 7.4%. No paraplegia or ischemic complications developed because of the coverage of the left subclavian artery. In one case (3.2%), a type I endoleak was detected, proximal endograft infolding in two cases (7.4%) and endograft distal migration in further two cases were detected during follow-up (6-110 months). Thoracic endovascular aneurysm repair of BAI showed encouraging results in terms of perioperative mortality and morbidity. Concerns still remain about the potential mid- and long-term complications in younger patients

Single-center experience in the treatment of visceral artery aneurysms

Background: Visceral artery aneurysms (VAAs), although rare, represent a life-threatening disease with high mortality rates. With the more frequent use of diagnostic tests, there has been an incidental detection of these lesions which are mostly asymptomatic. It follows that surgeons are increasingly called to decide on the most appropriate management of VAAs between an open surgical or endovascular approach and among the different endovascular options currently available. The aim of this retrospective study was to evaluate the results of open surgery and interventional endovascular strategies of visceral artery aneurysms with respect to technical success, therapy-associated complications, and postinterventional follow-up in the elective and emergency situation. Methods: From January 1992 to January 2017, 125 open surgical or endovascular interventions for VAA were performed at our institution. Once the VAA was diagnosed and the indication for treatment was assessed, the preoperative diagnostic work-up consisted of contrast computed tomography (CT) or magnetic resonance imaging (MRI) and, in some patients, digital subtraction angiography. Follow-up included clinical and duplex ultrasound scan (DUS) and contrast-enhanced ultrasound to assess the treated vessel patency and organ perfusion after 1, 6, and 12 months, and yearly thereafter. CT or MRI controls were also performed at 1 year of follow-up and only when DUS was not diagnostic or showed a complication thereafter. After the first 5 years of follow-up, the status of the patient was obtained by a structured telephone survey. Results: The treatment option was endovascular in 56 of 125 cases (44.8%). Technical success was 98.3%. In one case, the procedure was interrupted for the extensive dissection of the afferent vessel. Twenty-six patients were treated by coil embolization while 29 with covered stenting. The endovascular approach was in emergency in two cases (3.6%). In the endovascular group, mortality was nil. Complications occurred in 5 cases (8.9%): 1 subacute intestinal ischemia caused by superior mesenteric artery dissection, 2 aneurysm reperfusion, 1 stent thrombosis, and 1 massive splenic hematoma. In 69 (55.2%) cases, surgical treatment was preferred, with 24 VAA resections and 45 arterial reconstructions. In 20 cases (29%), open surgery was performed in emergency conditions. In the surgical group, 8 emergency patients (40%) died intraoperatively. The mortality after elective surgical interventions was nil. Complications after surgery were 4 graft late thrombosis (5.8%): asymptomatic in three cases and requiring splenectomy in one. Conclusions: There is no overall consensus regarding the indications for treatment of VAA. Currently in emergent setting, the endovascular approach should be considered as the first choice because of its reduced invasiveness, faster way to access and bleeding control; this accounts for the lower morality of the interventional therapy than open surgery. Endovascular approach is effective for elective repair of VAAs, but procedure-related complications may occur in a not negligible number of patients. Given comparable mortality rates and low procedure-related complication rate, surgical approach still has space in the elective management of VAAs, especially for aneurysms unsuitable or challenging for the endovascular option in patients with low surgical risk. The size, location, and morphology of VAAs, systemic or local comorbidities, and specific anatomical situations such as previous abdominal surgery should dictate treatment choice

Aorto-enteric Fistula following Abdominal Aortic Aneurysms Repair by Endograft

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Mid- and Long-Term Results of Endovascular Treatment in Thoracic Aorta Blunt Trauma

Study Aim. Evaluation of results in blunt injury of the thoracic aorta (BAI) endovascular treatment. Materials and Methods. Sixteen patients were treated for BAI. Thirteen patients had associated polytrauma, 4 of these had a serious hypotensive status and 4 had an hemothorax. In the remaining 3, two had a post-traumatic false aneurysm of the isthmus and 1 had a segmental dissection. In those 13 patients a periaortic hematoma was associated to hemothorax in 4. All patients were submitted to an endovascular treatment, in two cases the subclavian artery ostium was intentionally covered. Results. One patient died for disseminated intravascular coagulation. No paraplegia was recorded. No ischemic complications were observed. A type I endoleak was treated by an adjunctive cuff. During the followup (1–9 years) 3 patients were lost. A good patency and no endoleaks were observed in all cases. One infolding and 1 migration of the endografts were corrected by an adjunctive cuff. Conclusion. The medium and long term results of the endovascular treatment of BAI are encouraging with a low incidence rate of mortality and complications. More suitable endo-suite and endografts could be a crucial point for the further improvement of these results

Carotid body tumors: radioguided surgical approach

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Defining the characteristics of certified hernia centers in Italy: The Italian society of hernia and abdominal wall surgery workgroup consensus on systematic reviews of the best available evidences

Background: The terms “Hernia Center” (HC) and Hernia Surgeon” (HS) have gained more and more popularity in recent years. Nevertheless, there is lack of protocols and methods for certification of their activities and results. The Italian Society of Hernia and Abdominal Wall Surgery proposes a method for different levels of certification. Methods: The national board created a commission, with the task to define principles and structure of an accreditation program. The discussion of each topic was preceded by a Systematic Review, according to PRISMA Guidelines and Methodology. In case of lack or inadequate data from literature, the parameter was fixed trough a Commission discussion. Results: The Commission defined a certification process including: “FLC - First level Certification”: restricted to single surgeon, it is given under request and proof of a formal completion of the learning curve process for the basic procedures and an adequate year volume of operations. “Second level certification”: Referral Center for Abdominal Wall Surgery. It is a public or private structure run by at least two already certified and confirmed FLC surgeons. “Third level certification”: High Specialization Center for Abdominal Wall Surgery. It is a public or private structure, already confirmed as Referral Centers, run by at least three surgeons (two certified and confirmed with FLC and one research fellow in abdominal wall surgery). Both levels of certification have to meet the Surgical Requirements and facilities criteria fixed by the Commission. Conclusion: The creation of different types of Hernia Centers is directed to create two different entities offering the same surgical quality with separate mission: the Referral Center being more dedicated to clinical and surgical activity and High Specialization Centers being more directed to scientific tasks

Five-Year Follow-Up of a Slowly Resorbable Biosynthetic P4HB Mesh (Phasix) in VHWG Grade 3 Incisional Hernia Repair

OBJECTIVE: To assess the 5-year recurrence rate of incisional hernia repair in Ventral Hernia Working Group (VHWG) 3 hernia with a slowly resorbable mesh.SUMMARY BACKGROUND DATA: Incisional hernia recurs frequently after initial repair. In potentially contaminated hernia, recurrences rise to 40%. Recently, the biosynthetic Phasix mesh has been developed that is resorbed in 12-18 months. Resorbable meshes might be a solution for incisional hernia repair to decrease short- and long-term (mesh) complications. However, long-term outcomes after resorption are scarce.METHODS: Patients with VHWG grade 3 incisional midline hernia, who participated in the Phasix trial (Clinilcaltrials.gov: NCT02720042) were included by means of physical examination and computed tomography (CT). Primary outcome was hernia recurrence; secondary outcomes comprised of long-term mesh complications, reoperations, and abdominal wall pain [visual analogue score (VAS): 0-10].RESULTS: In total, 61/84 (72.6%) patients were seen. Median follow-up time was 60.0 [interquartile range (IQR): 55-64] months. CT scan was made in 39 patients (68.4%). A recurrence rate of 15.9% (95% confidence interval: 6.9-24.8) was calculated after 5 years. Four new recurrences (6.6%) were found between 2 and 5 years. Two were asymptomatic. In total, 13/84 recurrences were found. No long-term mesh complications and/or interventions occurred. VAS scores were 0 (IQR: 0-2).CONCLUSIONS: Hernia repair with Phasix mesh in high-risk patients (VHWG 3, body mass index &gt;28) demonstrated a recurrence rate of 15.9%, low pain scores, no mesh-related complications or reoperations for chronic pain between the 2- and 5-year follow-up. Four new recurrences occurred, 2 were asymptomatic. The poly-4-hydroxybutyrate mesh is a safe mesh for hernia repair in VHWG 3 patients, which avoids long-term mesh complications like pain and mesh infection.</p