AngioJetTM rheolytic thrombectomy with covered balloon-expandable stent deployment in a superior vena cava syndrome: a case report

The Superior Vena Cava Syndrome (SVCS) is a rare mediastinal syndrome, frequently due to compression by a mediastinal malignant leading to venous flow obstruction through the Superior Vena Cava (SVC) towards the heart. The symptoms may consist of edema of the upper body and distended veins, dyspnea up to a life-threatening condition. Restoring the SVC flow by endovascular means can be beneficial in order to achieve a rapid relief of the clinical symptoms. A 51-year-old male with a recent diagnosis of squamous cell lung tumor diagnosis presented to the emergency department with persistent cough, neck and face swelling, and distended jugular veins on clinical examination. No dyspnea and normal vital parameters were reported. Computed Tomography angiography (CT) examination demonstrated thrombosis of subclavian veins and SVC due to compression by malignancy. Compression also involved the right upper lobar bronchus. Through a percutaneous transvenous right humeral access, phlebography confirmed total occlusion of the right subclavian vein, brachiocephalic venous trunk, and superior vena cava. We performed AngioJetTM (Boston Scientific, Marlborough, MA, USA) rheolytic endovascular thrombectomy. The phlebography demonstrated the unlying hemodynamic stenosis due to the ab-extrinsic compression and underwent stenting with a covered balloon-expandable stent. The final phlebography confirmed the patency of the stent and restoration of venous flow. Although there was a complete recovery of the symptoms, the patient died from respiratory complications caused by malignancy involvement. AngioJetTM mechanical thrombectomy and covered balloon-expandable stent deployment is a useful solution for SVCS to quickly achieve relief of the clinical symptoms. There are few case series where thrombectomy and primary stent placement are studied. Further follow-up studies are needed to understand the patency of treated vessels better

Infrared Thermography as a Diagnostic Tool for the Assessment of Patients with Symptomatic Peripheral Arterial Disease Undergoing Infrafemoral Endovascular Revascularisations

Aim: The aim of this study was to evaluate the utility and reliability of temperature foot changes measured by infrared thermography (IRT) for the evaluation of patients with atherosclerotic peripheral arterial disease (PAD) before and after endovascular revascularisation. Methods: This is an observational prospective study carried out on symptomatic PAD patients. Evaluations consisted of a clinical examination, duplex scan with ankle–brachial index calculation (ABI) and IRT measurements with infrared camera FLIR-ONE connected to a smartphone with android technology. Locations on the foot sampled with IRT were the anterior tibial, pedal, posterior and arcuate arteries. Results obtained with IRT on the symptomatic foot were compared to the contralateral foot and with the ABI values obtained bilaterally before and 24 h after revascularisation. Results: Within one year, 40 patients were enrolled, among whom 87,5% suffered from critical limb ischaemia. In three patients, it was impossible to obtain ABI measurements because of ulcerations on the limb. Skin temperature changes obtained by IRT between the symptomatic limb and the contralateral limb had a mean difference of 1.7 °C (range: 1.1–2.2 °C), p < 0.001. There was a positive correlation between ABI and temperature values of the limb needed for treatment before revascularisation (p = 0.025; r = 0.36) and after revascularisation (p = 0.024, r = 0.31). The technical success rate was 100% in all cases, achieving a significant increase in temperature at all points of the foot analysed, with a median change of 2 °C (p < 0.001). Conclusion: IRT is a safe, reliable and simple application. It could be a valuable tool for the assessment of the clinical presentation and severity of foot blood perfusion in symptomatic PAD patients and the evaluation of the technical success of endovascular revascularisation. IRT might have a role in follow-up of revascularisation procedures

Biosynthetic graft failure to replace infected infrainguinal bypass as developing infection due to Morganella morganii leading to disrupture of the anastomosis. Case report

Introduction Biosynthetic prosthesis has become the trend to carry out arterial reconstruction in infected sites since considered to be resistant to infection. Late graft occlusion is the only complication reported in literature so far. We report a case of biosynthetic graft infection which led to early detachment of the femoral anastomosis of a femoral-popliteal above-knee bypass. Material A 76-year-old man developed groin infection 3 months later after performing an ePTFE femoral-popliteal above-knee bypass for critical limb ischemia. He was re-admitted for groin infection involving the vascular structures. Explantation of the existing bypass and its replacement with a biosynthetic graft (omniflow II) was performed. Detachment of the proximal anastomosis occurred 6 days later leading to groin haematoma. Consequently, retroperitoneal access was performed for clamping the external iliac artery so as to control haemorrhage followed by explantation of the biosynthetic graft. An external iliac-popliteal above-knee bypass was tailored in order to save the limb and it was performed using a transobturator approach avoiding the infected site. In both cases bacterial cultures resulted positive for Morganella Morganii. The groin wound was treated separately with negative pressure medication healing definitively within 20 days and after 3-month follow-up the bypass was still patent. Conclusion This is the first report of biosynthetic graft infection used for infrainguinal reconstruction leading to haemorrhage due to anastomosis disrupture. Using an extra-anatomical access for providing blood inflow to the leg avoiding the infected site and treating safely the groin wound with VAC therapy revealed to be a valid approach

Endovascular Revascularisation versus Open Surgery with Prosthetic Bypass for Femoro-Popliteal Lesions in Patients with Peripheral Arterial Disease

Aim: Complex atherosclerotic femoro-popliteal lesions have traditionally been treated with bypass surgery. A prosthetic graft is used to save the vein graft for more distal revascularisations or when a vein graft is unavailable. The endovascular approach has gained popularity and is offered as a first-line strategy for complex lesions. This study aimed to evaluate whether endovascular procedures can be used as a first-line treatment strategy for complex native femoro-popliteal lesions over open surgery with prosthetic bypass in patients with peripheral arterial disease (PAD). Methods: This single-centre retrospective observational study was conducted between 2013 and 2021; it included patients with symptomatic PAD who required limb revascularisation at the femoro-popliteal segment and who had complex lesions. The primary endpoints analysed were technical success, primary patency, freedom from clinically driven target lesion revascularisation (cdTLR), freedom from major adverse limb and cardiovascular events (MALE and MACE, respectively), freedom from limb loss, and survival. The secondary endpoints were length of in-hospital stay, and duration and costs of the procedure. Results: We identified 185 limbs among 174 suitable candidates for comparison, wherein 105 were treated with an endovascular procedure and 80 with a femoro-popliteal prosthetic bypass. Most patients in both groups presented with chronic limb-threatening ischaemia, and >90% of them had an American Society of Anesthesiologists (ASA) physical status classification of >3. The endovascular group had more octogenarians (p = 0.02) and patients with coronary disease (p = 0.004). The median follow-up was 30 months. The technical failure rate for endovascular procedures was 4.7%, versus 0% in the open group (p = 0.047). Freedom from MACE was similar in both groups. The endovascular group showed superior primary patency (p p p p = 0.0018) at 24 and 48 months. Further analysis performed for the open above-the-knee sub-group showed that the aforementioned endpoints were similar between the groups at 12 months and were better in the endovascular group at 24 and 48 months. Procedural time and in-hospital stay were longer in the open group than in the endovascular group (p p Conclusions: Endovascular procedures are safe for treating complex femoro-popliteal lesions in patients at a high risk for surgery and show better outcomes at 24 months than prosthetic bypasses do. The latter may be considered as an alternative should endovascular treatment fail

Is Venous Thromboembolism a Predictable Marker in Older Patients with COVID-19 Infection? A Single-Center Observational Study

Venous thromboembolism (VTE) represents an important clinical complication of patients with SARS-CoV-2 infection, and high plasma D-dimer levels could suggest a higher risk of hypercoagulability. We aimed to analyse if laboratory exams, risk assessment scores, comorbidity scores were useful in predicting the VTE in SARS-CoV-2 patients admitted in internal medicine (IM). We evaluated 49 older adults with suspected VTE analysing history and blood chemistry, besides we calculated the Padua Prediction Score, the modified early warning scoring (MEWS) and the modified Elixhauser index (mEI). All patients underwent venous color-doppler ultrasounds of the lower limbs. Out of the 49 patients enrolled (mean age 79.3±14 years), 10 (20.4%) had deep vein thrombosis (DVT), and they were more frequently female (80% vs 20%, p = 0.04). We could not find any association with the Padua Prediction Score, the MEWS, and the mEI. D-dimer plasma levels were also not associated with DVT. In elderly people hospitalized with SARS-CoV-2 infection hospitalized in IM, our data, although limited by the sample size, suggest that prediction and diagnosis of VTE is difficult, due to lack of precise biomarkers and scores

Exercise-based functional recovery from severe upper extremity arterial disease due to bilateral subclavian artery obstruction in a person with giant cell arteritis

We report the case of a 71-year-old woman diagnosed with giant cell arteritis with bilateral subclavian and axillary obstruction and severe arm claudication that occurred 3 months earlier and was non-regressed after corticosteroids. Before possible revascularization, the patient was initiated to a personalized home-based graded exercise program including walking, hand-bike pedaling, and muscle strength training. During the 9 months of treatment, the patient progressively improved radial pressure values (10 to 85 mmHg), hand temperature values by infrared-thermography (+2.1 °C), arm endurance, and forearm muscle oxygenation by near-infrared spectroscopy. Home-based graded exercise proved to be a noninvasive option for upper limb claudication

BEST MEDICAL THERAPY AS AN ALTERNATICE TO SURGERY FOR BORDER LINE SYMPTOMATIC CAROTID STENOSIS

BACKGROUND: According to several trials for patients with carotid symptomatic stenosis of 50-69% it is recommended an invasive treatment in order to prevent from recurrent ischemic cerebral events. However, for this subgroup the benefits of surgery have been demonstrated to be only marginal in stroke prevention and they remain unclear in women. Moreover, it is demonstrated that early surgery for symptomatic is accompanied by a high procedural risk of stroke/death less. In order to choose the optimal treatment we tried to evaluate whether medical therapy in this subgroup of patients could be an effective and safe approach. METHODS: The data have been collected retrospectively for each patient evaluated in vascular outpatients who suffered from any ischemic cerebral event and congruent carotid with 50-69% stenosis who did not receive an invasive treatment. Primary end points were considered ischemic recurrence, survival rate and carotid stenosis degree evolution during the follow-up. RESULTS: From January 2013 to January 2015 were identified 43 patients who suffered from ischemic cerebral lesion (TIA or stroke) and carriers of congruent carotid stenosis of 50-69% confirmed to both CT and duplex scan evaluation. The frequency of clinical and duplex scan evaluation was at 1 month after the discharge, at 3 months and every 6 months thereafter. Median follow-up was 36 months with at least 24-months follow-up for each patient. Mean age was 71 years (range: 60-83 years). In these patients medical therapy was undertaken within 12 hours from the onset of the symptomatology. In 32 patients was set up antiplatelet therapy and in 8 patients an anticoagulant therapy as atrial fibrillation was found out. In 2 patients was maintained the former anticoagulant therapy as they suffered from cardiac valvulopathy. Therapy with statins was set up in all patients despite dyslipidemia was found only in 55.8% of patients. Antihypertensive therapy was not necessary in 16%. In 12 patients with high blood homocysteine values was carried out a cyclic therapy with folate and group-B vitamins. Thirteen patients were smokers and it was strongly recommended cessation. The adherence to drug therapy was almost 100% unlike smoke cessation which was less than 50%. Mortality rate at 30 days was 2.3%. Recurrent ischemic event rate was 2.3% within 3 months and free from recurrences in the remaining duration of the follow-up. Carotid stenosis degree evolution more than 70% occurred in 4.6% and 6.9% respectively within 1 and 3 years and indication to CEA was given. CONCLUSIONS: In this study conservative management revealed to be a safe approach for patients with ischemic lesion and congruent carotid borderline stenosis in terms of mortality and preventing from recurrent cerebral ischemic events. Performing a strict clinical and instrumental surveillance in order to address selected patients to CEA increases the safety of medical approach

Primary drug-coated balloon versus drug-eluting stent for native atherosclerotic femoropopliteal lesions: A systematic review and meta-analysis

Objective: In this systematic review and meta-analysis, we aimed to compare drug-coated balloon (DCB) to drug-eluting stent (DES) angioplasty as a primary option in patients with femoropopliteal lesions in terms of primary patency and freedom from clinically driven target lesion revascularization (cdTLR) and major adverse limb events (MALE). Methods: A comprehensive literature search was performed using the PubMed and Embase databases. All studies written in English language and reporting data presenting a comparison between patients receiving primary percutaneous balloon angioplasty using the DCB versus primary percutaneous stenting with DES for native femoropopliteal lesions were included in this meta-analysis. Results: There were 984 patients with 1078 femoropopliteal lesions, of which procedures with DCB and DES were performed in 514 and 564 lesions, respectively. Overall, majority patients were men with a mean age of 70.9 years; and there were no significant differences between the two groups regarding the cardiovascular comorbidities. With regards to the procedural strategy, there was significant heterogeneity in the DCB group. This included adjunctive procedures such as atherectomy besides the angioplasty of the target vessel, which was reported in one study as a part of 32.1% of the procedures in the DCB group. Provisional bare metal stents (pBMS) for residual stenosis and dissection were used in four studies with a percentage varying from 14.8-25.3%. Overall, at 1 year, all outcomes were similar for all the endpoints; however, where adjunctive procedures were performed (atherectomy + pBMS) in the DCB group, the outcomes were better (primary patency p.001, freedom cdTLR p.001, freedom form MALE p.002). In studies where no adjunctive procedures were performed in the DCB group, the results favored the DES group for the primary patency (p.026) and freedom from cdTLR (p.044). Conclusions: DES seems to be superior in terms of cdTLR and primary patency at 1 year when compared to the procedures performed solely with DCB. For DCB to achieve optimal results, further adjunctive procedures such as pBMS and atherectomy are needed. More studies are needed to confirm the superiority of the primary stenting with DES at the femoropopliteal segment

Real-world outcomes of Cook Zilver PTX in femoro-popliteal district from multicenter experience

The purpose is to evaluate the follow-up outcomes after femoro-popliteal stenting with Cook Zilver PTX in a multicenter experience