Treatment of vascular access-related steal syndrome by means of juxta-anastomotic vein interposition of a prosthetic graft segment

Objective: Steal syndrome is a severe complication of vascular access. Our aim is to present the initial results of a simple and effective treatment: the interposition of a prosthetic segment in the juxta-anastomotic vein. Method: Between 2009 and 2012, 14 patients (57 % male, average age 71) with severe steal syndrome due to native vascular access (stages II-IV), following a clinical and systematic echographic study and a selective angiographic study, were treated through the interposition of a 6 mm diameter tubular graft segment (PTFE) in the juxta-anastomotic vein, in addition to selective patch repair of arterial stenosis (2 cases) or ligature of useless venous collaterals (8 cases). Local or regional anaesthesia was used and outpatient care was given in all cases. Results: There was 100 % technical success. The pre- and post-operative echographical study showed a reduction of post-operative access flow by 39 % and an increase of radial artery flow by 477 %. Ischaemic symptoms were resolved in 12 patients (86 %); the other two patients required additional procedures due to persistent ischaemic symptoms. There was a post-operative venous rupture, which required a definitive ligation. No patient suffered amputations, nor were there losses or access thrombosis during the follow-up. The primary and primaryassisted patencies free of new ischemic symptoms were 78 % and 78 % at 12 months, and 62 % and 78 % at 24 months. Conclusions: The interposition of a prosthetic segment in the juxta-anastomotic vein is a simple, quick and effective technique in the treatment of vascular steal syndrome, with promising results at the 2 year follow-up

Diagnostic yield of 18F-FDG PET/CT in suspected diagnosis of vascular graft infection: A prospective cohort study

Background. Prosthetic vascular graft infection (PVGI) is a severe complication associated with high morbidity and mortality. Clinical diagnosis is complex, requiring image testing such as CT angiography or leukocyte scintigraphy, which has considerable limitations. The aim of this study was to know the diagnostic yield of PET/CT with 18F-Fluorodeoxyglucose (18F-FDG) in patients with suspected PVGI. Methods. We performed a prospective cohort study including 49 patients with suspected PVGI, median age of 62 ± 14 years. Three uptake patterns were defined following published recommendations: (i) focal, (ii) patched (PVGI criteria), and (iii) diffuse (no PVGI criterion). Results. Sensitivity, specificity, and positive and negative predictive values for 18F-FDG-PET/ CT were 88%, 79%, 67%, and 93%, respectively. 18F-FDG-PET/CT identified 14/16 cases of PVGI showing a focal (n = 10) or patched pattern (n = 4), being true negative in 26/33 cases with either a diffuse pattern (n = 16) or without uptake (n = 10). Five of the seven false-positive cases (71%) showed a patched pattern and all coincided with the application of adhesives for PVG placement. Conclusions. 18F-FDG-PET/CT is a useful technique for the diagnosis of PVGI. A patched pattern on PET/CT in patients in whom adhesives were applied for prosthetic vascular graft placement does not indicate infection. (J Nucl Cardiol 2018) Key Words: Fluorodeoxyglucose (FDG) Æ diagnostic and prognostic application Æ PET/CT imagin

FEVAR /BEVAR have limitations and do not always represent the preferred option for juxtarenal reconstruction

Following the definition given by the recent ESVS guidelines, juxtarenal abdominal aortic aneurysm (JAAA) is defined as an aneurysm extending up to but not involving the renal arteries, necessitating suprarenal aortic clamping for open surgery, i.e. a short neck (<10 mm). JAAA repair always represents a challenge intervention, either by open or endovascular means, mostly related to the renal arteries involvement. Concerning endovascular repair, different options can be considered. Among them, fenestrated endografts (FEVAR) should be considered as a first option1, due to their reported safety and efficacy. However, when the anatomy is not favorable or when FEVAR devices are not available in an emergency setting for instance, other alternatives can be considered like parallel graft or chimney technique (ChEVAR). Do nothing is the last alternative when medical and anatomical circumstances are absolutely poor. In the following pages, we will review the limitations of FEVAR and branched endografts, the better indications and anatomical conditions for a successful repair with ChEVAR technique and its current clinical results reported in the literature

The most relevant unmet needs in endovascular management of descending thoracic aorta

Endovascular repair of descending thoracic aorta (DTA) is considered as first interventional option for most part of the aortic disorders. However, many unmet needs and issues are still limiting its applicability. One of the major limitations is related to the existing gaps in evidence. Clear and robust evidence is still needed in many aspects of the management of DTA pathologies. In numerous clinical scenarios, adequate trials are lacking. Besides those gaps in evidence, it is well recognized that thoracic endografting (TEVAR) is technically evolving in order to overcome technical and device-related complications and limitations. We can deploy endografts in any aortic segment: in the descending, in the ascending, in the arch, even preserving aortic branches. Nevertheless, from the pure technical point of view, current generations of endografts still need more development and improvement. Durability remains the major concern for any endovascular treatment, and thoracic endografting is not an exception. As Galenus said, the physician is only nature’s assistant, thoracic endograft should also follow the natural anatomy instead of fighting against it. We will focus the following pages on the graft conformability and compliance, both related to durability and safety of thoracic endografting. We will review the current knowledge and concerns associated with the anatomical and hemodynamic modifications induced by the thoracic endograft strength, stiffness and straightness and their implications for the future thoracic endograft designs