Endovascular balloon assistance during hip disarticulation

Objective Limb disarticulation has been widely performed since the 18th century, especially in war surgery. Actually is infrequently done in orthopaedic and vascular surgery, and it is associated with a high mortality rate because of frequent comorbidities. Disarticulation usually is reserved for patients with malignant tumours or gangrene from severe artherosclerosis. During disarticulation, hemodynamic stability can be altered by hemorrhagic events in the femoral or humeral arteries. We propose an endovascular technique for proximal control of the artery to reduce blood loss during disarticulation. Our experience today is limited at hip disarticulation. Material and methods The vascular access was percutaneous at the common femoral artery of the healthy limb. A 6 French (Fr) introducer sheath was placed using the Seldinger technique. Under fluoroscopic control, with a portable vascular C-arm capable of digitally subtracter angiogram and roadmap angiography, a 0.035 inch hydrophilic guide wire was crossed aver into the opposite side iliac artery through a 5F contra angiographic catheter placed at the aortic bifurcation. After a diagnostic angiography the guide wire was replaced with an Amplatz 0.0035 inch, 260 cm long, super stiff guide wire. Then, a 7 9 20 mm Ultra-thinTM SDS balloon catheter was placed in the external iliac artery and systemic heparinization with 2500 UI was performed. The balloon catheter was inflated and femoral pulsation ceased immediately. After proximal, endovascular occlusion, hip disarticulation was accomplished without any hemorrhagic complication. At the end of procedure, the balloon was deflated and removed. Hemostasis of the surgical field completed the procedure. The femoral access in the healthy common femoral artery was controlled with a 6 Fr Angio-seal percutaneous hemostatic system. Results and discussion In hip disarticulation, hemostatic tourniquets cannot be used of the location of the operating field. Therefore, control of bleeding is a major issue in this procedure. Various techniques have been proposed, femoral vessels and nerves were attached before the disarticulation. The use of semi-compliant balloon catheters for endovascular occlusion avoids injury to the endothelium of the vessel wall during balloon inflation. However preoperative assessment, with color-duplex scanning and plain abdominal radiographs, is mandatory; coexisting atherosclerosis often is present especially in elderly patients, and severe wall calcification can lead to vessel rupture and retroperitoneal hematoma, or even balloon catheter rupture. Moreover, color-duplex scanning and radiographs will help in choosing the landing-zone for balloon inflation. Conclusions Endovascular balloon assistance is a simple, safe and effective technique in preventing major arterial bleeding during amputation or disarticulation and can be routinely used

The carotid wallstent for the endovascular treatment of carotid artery stenosis

Aim: To report a retrospective, 15-years single-center experience about Carotid Artery Stenting (CAS) using the Carotid Wallstent in high surgical risk patients. Methods: Primary outcomes were procedural success, 30-day mortality and cerebrovascular complications, and long-term survival, neurological complication and restenosis. P values< 0.05 were considered significant. Results: From January 2000 to June 2015, 560 patients underwent CAS using the Carotid Wallstent for either a symptomatic (22.6%) or an asymptomatic significant carotid stenosis. Primary success was achieved in 99.1% as 4 acute stent thrombosis occurred and in 1 case selective catheterization of the supra-aortic trunks was not possible due to extreme tortuosity. At 30 days, 7 TIAs and 9 strokes accounted for a 2.8% of neurological complication rate. There were 2 deaths unrelated to the procedure. At 10 years, survival was 71.2% +/- 2.5%. Freedom from cerebrovascular events (TIA/stroke) at 10 years was 91.2% +/- 1.9% for asymptomatic patients and 81.7% +/- 5% for symptomatic patients (P = 0.008). Freedom from a restenosis >30% was estimated to be of 93.9% +/- 1.3% at 10 years, being significantly affected by age (P = 0.01). Conclusion: In our experience the Carotid Wallstent was a safe and effective device for the treatment of both asymptomatic and symptomatic carotid stenosis in high surgical risk patients. Freedom from cerebrovascular events in the long term was worse in symptomatic patients

Ruptured hemiarch and descending thoracic aorta aneurysm : hybrid treatment

Ruptured aortic arch aneurysm is a life threatening disease. Surgical repair has an high perioperative mortality rate and totally endovascular treatment is a challenge. Hybrid repair has been proposed as a valuable approach. We report the case of a patient with a contained rupture of aortic arch aneurysm. We treated him with a debranching of supraortic vessels with carotid-carotid and carotid-subclavian bypass and deployment of two enodgrafts in two different times. We consider hybrid treatment for arch and hemiarch a feasible option for aortic arch aneurysms in non emergent and in an emergency setting with an improvement in perioperative morbidity and mortality

Weapons in the jungle of femoro-popliteal lesions

Best treatment for Superficial Femoral Artery (SFA) lesions is still the subject of some controversies in the literature. The paper offers a brief overview of all the techniques currently available for the treatment of SFA lesions

Straight aortic endograft in abdominal aortic disease

Background: We describe our 8-year experience with the use of endovascular techniques (ET) for the treatment of abdominal aortic aneurysms (AAA) through a straight endograft. Methods: We retrospectively reviewed data of all patients who were treated for AAA using ET in two centres from 1998 to 2012 and who received a single straight endograft (group A) or a double straight tube (group B). Outcomes were analyzed to assess survival, absence of endoleak and absence of reintervention for both groups. Log-rank and Chi-Square were used as appropriate to make comparison between the two groups. P values <.05 were considered statistically significant. Results: Fifty-three patients from 1998 to May 2012 were treated for AAA using a straight endograft. In 28 cases (52.8%) a single aortic straight tube was used (Group A), while in the remaining cases a "double trombone technique" was used (Group B). Primary success was obtained in 52 cases (98.1%). In one patient of group A immediately after the operation we observed a type Ia endoleak, which was correct with a proximal aortic cuff. Fluoroscopy time, operation time, amount of intraprocedural contrast medium and blood loss were slightly higher for group B, even if not significantly. Mortality at 30 days was nil for both groups. Mean follow-up was 49 months (range 2-153 months). Five patients died in group A, four of them for a neoplastic disease and the remaining for aortic rupture. No patients died in group B. Endoleaks occurred more frequently in patients of group A (5 type I endoleaks and 1 type II endoleak from a lumbar artery). Reintervention were more frequent for patients of group A, being type I endoleak the main cause. A stent fracture was observed in a patient who received EVAR by "trombone technique" 3 months later. Reintervention was then necessary and a third stent was successfully placed to cover the lesion. Conclusions: In our experience the endovascular repair of AAA using straight aortic endografts was a safe and effective technique. Reintervention and endoleaks were slightly more frequent in patients who had received a single endograft compared to patients who were treated using the "trombone technique"

Hybrid endovascular and surgical approach for mycotic pseudoaneurysms of the extracranial internal carotid artery

Objectives: Mycotic pseudoaneurysms of the extracranial internal carotid artery are rare, and their management often represents a challenge, but treatment is necessary due to the high risk of rupture and distal brain embolization. Systemic antibiotics associated with open surgical excision of the infected tissues and carotid reconstruction using autologous grafts are the treatment of choice. The use of endovascular techniques still remains controversial in infective fields; however, it can be an attractive alternative in high-risk patients or more often as a \u201ctemporary\u201d solution to achieve immediate bleeding control for a safe surgical reconstruction. Methods: We discuss the unusual case of an extracranial right internal carotid artery mycotic pseudoaneurysm following methicillin-resistant Staphylococcus aureus infection, in a patient with poor general conditions. Results and Conclusion: The lesion was successfully treated using a hybrid endovascular and surgical procedure

Status Update and Interim Results from the Asymptomatic Carotid Surgery Trial-2 (ACST-2)

Objectives: ACST-2 is currently the largest trial ever conducted to compare carotid artery stenting (CAS) with carotid endarterectomy (CEA) in patients with severe asymptomatic carotid stenosis requiring revascularization. Methods: Patients are entered into ACST-2 when revascularization is felt to be clearly indicated, when CEA and CAS are both possible, but where there is substantial uncertainty as to which is most appropriate. Trial surgeons and interventionalists are expected to use their usual techniques and CE-approved devices. We report baseline characteristics and blinded combined interim results for 30-day mortality and major morbidity for 986 patients in the ongoing trial up to September 2012. Results: A total of 986 patients (687 men, 299 women), mean age 68.7 years (SD ± 8.1) were randomized equally to CEA or CAS. Most (96%) had ipsilateral stenosis of 70-99% (median 80%) with contralateral stenoses of 50-99% in 30% and contralateral occlusion in 8%. Patients were on appropriate medical treatment. For 691 patients undergoing intervention with at least 1-month follow-up and Rankin scoring at 6 months for any stroke, the overall serious cardiovascular event rate of periprocedural (within 30 days) disabling stroke, fatal myocardial infarction, and death at 30 days was 1.0%. Conclusions: Early ACST-2 results suggest contemporary carotid intervention for asymptomatic stenosis has a low risk of serious morbidity and mortality, on par with other recent trials. The trial continues to recruit, to monitor periprocedural events and all types of stroke, aiming to randomize up to 5,000 patients to determine any differential outcomes between interventions. Clinical trial: ISRCTN21144362. © 2013 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved

Second asymptomatic carotid surgery trial (ACST-2): a randomised comparison of carotid artery stenting versus carotid endarterectomy

Background: Among asymptomatic patients with severe carotid artery stenosis but no recent stroke or transient cerebral ischaemia, either carotid artery stenting (CAS) or carotid endarterectomy (CEA) can restore patency and reduce long-term stroke risks. However, from recent national registry data, each option causes about 1% procedural risk of disabling stroke or death. Comparison of their long-term protective effects requires large-scale randomised evidence. Methods: ACST-2 is an international multicentre randomised trial of CAS versus CEA among asymptomatic patients with severe stenosis thought to require intervention, interpreted with all other relevant trials. Patients were eligible if they had severe unilateral or bilateral carotid artery stenosis and both doctor and patient agreed that a carotid procedure should be undertaken, but they were substantially uncertain which one to choose. Patients were randomly allocated to CAS or CEA and followed up at 1 month and then annually, for a mean 5 years. Procedural events were those within 30 days of the intervention. Intention-to-treat analyses are provided. Analyses including procedural hazards use tabular methods. Analyses and meta-analyses of non-procedural strokes use Kaplan-Meier and log-rank methods. The trial is registered with the ISRCTN registry, ISRCTN21144362. Findings: Between Jan 15, 2008, and Dec 31, 2020, 3625 patients in 130 centres were randomly allocated, 1811 to CAS and 1814 to CEA, with good compliance, good medical therapy and a mean 5 years of follow-up. Overall, 1% had disabling stroke or death procedurally (15 allocated to CAS and 18 to CEA) and 2% had non-disabling procedural stroke (48 allocated to CAS and 29 to CEA). Kaplan-Meier estimates of 5-year non-procedural stroke were 2·5% in each group for fatal or disabling stroke, and 5·3% with CAS versus 4·5% with CEA for any stroke (rate ratio [RR] 1·16, 95% CI 0·86–1·57; p=0·33). Combining RRs for any non-procedural stroke in all CAS versus CEA trials, the RR was similar in symptomatic and asymptomatic patients (overall RR 1·11, 95% CI 0·91–1·32; p=0·21). Interpretation: Serious complications are similarly uncommon after competent CAS and CEA, and the long-term effects of these two carotid artery procedures on fatal or disabling stroke are comparable. Funding: UK Medical Research Council and Health Technology Assessment Programme

Diagnosis and treatment of abdominal aortic endoleaks using color Doppler US: two clinical cases

Endovascular treatment of abdominal aortic aneurysm (AAA) involves placement of an endoluminal graft inside the aneurysmal sac in order to exclude it from blood circulation and thereby prevent the risk of aneurysmal sac rupture. A possible complication is endoleak, i.e. persistent blood flow outside the lumen of the endograft into the aneurysmal sac. The protocol for treatment monitoring includes abdominal computed tomography (CT) and color Doppler ultrasound (US). The aim of this case report is to present our experience in two cases of endoleak in which diagnosis and treatment were carried out using color Doppler US