A scoping review on the approaches for cannulation of reno-visceral target vessels during complex endovascular aortic repair

OBJECTIVES: The aim of this study was to assess the approaches to reno-visceral target vessels (TVs) cannulation during branched-fenestrated endovascular aortic repair, determine the evidence base that links these approaches to clinical outcomes and identify literature gaps. METHODS: A scoping review following the PRISMA Protocols Extension for Scoping Reviews was performed. Available full-text studies published in English (PubMed, Cochrane and EMBASE databases; last queried, 31 June 2022) were systematically reviewed and analysed. Data were reported as descriptive narrative or tables, without any statistical analysis nor quality assessment. RESULTS: Fourteen retrospective articles were included. Seven articles studied the use of upper extremity access (UEA) during branched-fenestrated endovascular aortic repair, 3 studied the use of steerable sheaths and 4 included both approaches. A left UEA was used in 757 patients (technical success: 99%, stroke rate: 1-3%) and a right UEA in 215 patients (technical success: 92-98%, stroke rate: 0-13%). Seven studies (1066 patients) described a surgical access only (technical success: 80-99%, stroke rate: 0-13%), while 3 studies (146 patients) described a percutaneous access only (technical success: 83-90%, stroke rate: 3%) and lastly 4 studies compared UEA versus use of steerable sheaths from the transfemoral approach (TFA) (UEA: 563 patients, technical success: 95-98%, stroke rate: 1-8%; TFA: 209 patients, technical success: 98-100%, stroke rate: 0-1%). CONCLUSIONS: Both UEA and TFA as cannulation approaches were associated with high technical success and low perioperative complications. Currently, there is a paucity of high-quality data to provide definitive indication. Optimal UEA in terms of side (left versus right) and approach (surgical versus percutaneous) needs further study

Peri-Operative Management of Patients Undergoing Fenestrated-Branched Endovascular Repair for Juxtarenal, Pararenal and Thoracoabdominal Aortic Aneurysms: Preventing, Recognizing and Treating Complications to Improve Clinical Outcomes

The advent and refinement of complex endovascular techniques in the last two decades has revolutionized the field of vascular surgery. This has allowed an effective minimally invasive treatment of extensive disease involving the pararenal and the thoracoabdominal aorta. Fenestrated-branched EVAR (F/BEVAR) now represents a feasible technical solution to address these complex diseases, moving the proximal sealing zone above the renal-visceral vessels take-off and preserving their patency. The aim of this paper was to provide a narrative review on the peri-operative management of patients undergoing F/BEVAR procedures for juxtarenal abdominal aortic aneurysm (JAAA), pararenal abdominal aortic aneurysm (PRAA) or thoracoabdominal aortic aneurism (TAAA). It will focus on how to prevent, diagnose, and manage the complications ensuing from these complex interventions, in order to improve clinical outcomes. Indeed, F/BEVAR remains a technically, physiologically, and mentally demanding procedure. Intraoperative adverse events often require prolonged or additional procedures and complications may significantly impact a patient’s quality of life, health status, and overall cost of care. The presence of standardized preoperative, perioperative, and postoperative pathways of care, together with surgeons and teams with significant experience in aortic surgery, should be considered as crucial points to improve clinical outcomes. Aggressive prevention, prompt diagnosis and timely rescue of any major adverse events following the procedure remain paramount clinical needs

Profiling Insulin Like Factor 3 (INSL3) Signaling in Human Osteoblasts

Abstract BACKGROUND: Young men with mutations in the gene for the INSL3 receptor (Relaxin family peptide 2, RXFP2) are at risk of reduced bone mass and osteoporosis. Consistent with the human phenotype, bone analyses of Rxfp2(-/-) mice showed decreased bone volume, alterations of the trabecular bone, reduced mineralizing surface, bone formation, and osteoclast surface. The aim of this study was to elucidate the INSL3/RXFP2 signaling pathways and targets in human osteoblasts. METHODOLOGY/PRINCIPAL FINDINGS: Alkaline phosphatase (ALP) production, protein phosphorylation, intracellular calcium, gene expression, and mineralization studies have been performed. INSL3 induced a significant increase in ALP production, and Western blot and ELISA analyses of multiple intracellular signaling pathway molecules and their phosphorylation status revealed that the MAPK was the major pathway influenced by INSL3, whereas it does not modify intracellular calcium concentration. Quantitative Real Time PCR and Western blotting showed that INSL3 regulates the expression of different osteoblast markers. Alizarin red-S staining confirmed that INSL3-stimulated osteoblasts are fully differentiated and able to mineralize the extracellular matrix. CONCLUSIONS/SIGNIFICANCE: Together with previous findings, this study demonstrates that the INSL3/RXFP2 system is involved in bone metabolism by acting on the MAPK cascade and stimulating transcription of important genes of osteoblast maturation/differentiation and osteoclastogenesis

The PETTICOAT Technique for Complicated Acute Stanford Type B Aortic Dissection Using a Tapered Self-Expanding Nitinol Device as Distal Uncovered Stent

Background Provisional Extension To Induce Complete Attachment (PETTICOAT) technique has shown good results in the treatment of acute type B aortic dissections (ABAD). Usually, uncovered tubular stainless steel stents are used to promote distal true lumen reattachment. Methods We describe the Petticoat technique using a conic self-expanding nitinol device as distal uncovered stent in five cases of complicated ABAD. We used as distal uncovered stent the single-flared E-XL (Jotec-GmbH). Results In one case, renal arteries were successfully stented through the large cells of the E-XL. No perioperative complications were reported. During follow-up (18–24 months), positive remodeling of the entire aorta occurred in 3 cases; in 1 case with associated thoracoabdominal aneurysm, false lumen thrombosis at the thoracic level with true lumen expansion at the visceral aorta was detected at the 18-month CT angiogram, and in 1 patient with Marfan syndrome, open surgical conversion with the E-XL explantation was performed after 24 months due to aneurysmal evolution at the visceral level. Conclusions The E-XL can be successfully used in ABAD. It adapts to different aortic diameters, and its major radial force promotes successful positive remodeling. The open cell structure allows visceral arteries stenting, and it can be removed without complications during open conversion

Clinical Impact of Routine Cardiology Consultation Prior to Elective Carotid Endarterectomy in Neurologically Asymptomatic Patients

Objective: The aim was to determine the clinical impact of routine cardiology consultation before carotid endarterectomy (CEA) in neurologically asymptomatic patients, in terms of early and long term cardiovascular events. Methods: A single centre retrospective review of consecutive patients receiving CEA from 2007 to 2017 for asymptomatic carotid stenosis was performed. Two groups were compared: patients operated on from 2007 to 2012 received a pre-operative cardiology consultation only in selected cases (group A); from 2012 to 2017 patients received a routine pre-operative cardiology consultation (group B). In hospital death, myocardial infarction (MI), heart failure, dysrhythmias, and stroke were compared. A multiple logistic regression was performed to identify predictors of peri-operative complications. Long term overall survival and freedom from fatal cardiovascular events were compared. Results: In total, 878 CEAs were performed in group A and 1094 in group B. Patients in group B were more likely to have had a previous coronary intervention (0.5% vs. 5.1%; p < .001), and to be on dual antiplatelet (4.6% vs. 9.5%; p = .001), statin therapy (60.3% vs. 72.4%; p < .001), and a higher number of cardiac drugs (1.77 \ub1 1.22 vs. 1.92 \ub1 1.23; p = .01) at the time of CEA. In hospital mortality was 0.1% for both groups (p = 1.0), and there were no significant differences regarding neurological complications (0.8% vs. 0.3%; p = .20); group B had a significant reduction in overall cardiac complications (3.4% vs. 1.9%; p = .05) and MI (1.6% vs. 0.6%; p = .05). Multivariable analysis confirmed that routine cardiology consultation was an independent predictor of MI (odds [OR] ratio 0.61; p = .04) and overall reduction in cardiac complications (OR 0.28; p = .01). At five years, overall survival was similar (84.2% vs. 82.4%; p = .72), but patients in group B had a significantly lower mortality from cardiovascular events (92.0% vs. 95.8%; p = .04). Conclusion: Routine cardiology consultation before elective CEA in patients with asymptomatic carotid stenosis reduced peri-operative cardiac complications and long term fatal cardiovascular events. This approach may be considered to maximise the risk/benefit ratio of CEA in asymptomatic patients