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Caradu C.,Bordeaux University Hospital Center | Morin J.,Bordeaux University Hospital Center | Poirier M.,Unit of Vascular Surgery | Midy D.,Bordeaux University Hospital Center | Ducasse E.,Bordeaux University Hospital Center
Annals of Vascular Surgery | Year: 2017

Background: With approval of on-label fenestrated (F-) endovascular aortic repair (EVAR), concerns regarding long-term patency and endoleaks (ELs) after chimney graft (CG)-EVAR were raised. To add supportive data on the value of this technique, we chose to report the midterm results of CG-EVAR in a single center with standardized methods and to compare them to F-EVAR. Methods: A retrospective analysis of prospectively gathered data from January 2010 to January 2015 was conducted, and patients with excessive comorbidities for open repair treated by CG-EVAR or F-EVAR were included. Results: Ninety patients were treated by F-EVAR (88 men, 198 targets vessels) and 31 by CG-EVAR (26 men, 39 targets vessels, 12.9% treated in emergency; P = 0.001). Mean age was significantly higher in the CG group (71.3 ± 8.2 years in the FG group vs. 75.3 ± 6.6; P = 0.02), and there were significantly more patients suffering from preoperative chronic kidney disease (CKD) (13 [14.4%] treated by F-EVAR vs. 12 [38.7%]; P = 0.009). Target vessels were successfully reconstructed in 99.0% (196/198 target vessels) vs. 97.4% (38/39 target vessels) of cases (P = 0.3). In-hospital mortality was significantly higher after CG-EVAR (3.3% vs. 16.1%; P = 0.03). Incidence of acute kidney injury and CKD did not differ significantly between both groups. At 12 and 24 months, overall survival was 91.4% after F-EVAR vs. 82.1% and 81.8% vs. 69.0% (P = 0.4), estimated freedom from aneurysm related reintervention was 93.3% vs. 82.1% and 84.9% vs. 82.1% (P = 0.6), and target vessel's primary patency rate was 97.5% vs. 89.9% (P = 0.06), respectively. Freedom from type I EL's survival was significantly higher after F-EVAR at 12 and 24 months (100% vs. 89.0% and 97.7% vs. 89.0%; P = 0.01), but aneurysm maximum transverse diameter decrease did not differ significantly. Conclusions: There are potential advantages to CG-EVAR with off-the-shelf availability, versatility, and low-profile devices. In this series, patients treated by CG-EVAR showed promising and durable midterm results compared with F-EVAR. CG-EVAR and F-EVAR should not be apprehended as opposed strategies but more as complementary ones, while the best indications for CG-EVAR are clarified. © 2017 Elsevier Inc.


Ferraresi R.,Peripheral Interventional Unit | Hamade M.,Unit of Vascular Surgery | Gallicchio V.,Unit of Vascular Surgery | Troisi N.,San Giovanni Of Dio Hospital | Mauri G.,Radiology Unit
European Radiology | Year: 2016

Objectives: To describe the hydrodynamic boost (HB) technique and report our preliminary results with this technique in the subintimal angioplasty of below-the-knee vessels. Methods: HB was used in 23 cases (14 males, mean age 73 ± 12 years) of critical limb ischemia, with long chronic total occlusion of tibial arteries extended to the ankle level. The operator performs a manual injection of diluted contrast dye through a 4 F catheter into the subintimal space, close to the patent true distal lumen, in order to achieve a tear in the intimal flap and a connection with the true lumen. Results: In 19/23 (83 %) cases, the HB was effective in creating a connection between the subintimal space and the true distal lumen and it was possible to advance a wire and to conclude the procedure. In 4/23 (17 %) lesions, the HB failed and the procedure was successfully completed by retrograde approach. No major complications occurred. Mean length between catheter tip and re-entry point was 8 ± 5 mm. Conclusions: HB seems to be a feasible, safe and effective re-entry technique in distal below-the-knee vessels. This method represents an easy option for re-entry that extends the possibility of antegrade approach to obtain a successful revascularization. Key points: • In subintimal angioplasty of below-the-knee vessel re-entry can represent a challenge. • Inability to re-enter may determine the failure of the revascularization procedure. • HB is a novel re-entry technique feasible in distal below-the-knee vessels. • HB may increase the success rate of antegrade approach. • In case of failure, retrograde approach remains feasible. © 2015, European Society of Radiology.


Guy Bianchi P.,IRCCS Instituto Auxologico Italiano | Tolva V.,IRCCS Instituto Auxologico Italiano | Dalainas I.,National and Kapodistrian University of Athens | Bertoni G.,IRCCS Instituto Auxologico Italiano | And 4 more authors.
International Angiology | Year: 2012

Aim. The aim of this preliminary study is to evaluate the feasibility and efficacy of CAS as treatment option to endarterectomy when carotid shunt cannot be used safely. Methods. The medical records concerning 469 carotid stenosis treated between January 2006 and December 2009 were retrospectively reviewed, focusing on cross-clamp intolerance during CEA. Patients with cross-clamping intolerance were divided in two groups. Group 1: those that concluded the open procedure with the use of a shunt, and Group 2: those who experience immediate brain intolerance and coma and were immediately converted to an endovascular procedure. Mortality and neurological adverse event rate were compared between shunted CEA and cross-clamping intolerant cases converted into CAS. The secondary end-point was long-term survival. Results. Carotid cross-clamp intolerance occurred in 30 cases (8.7%). CEA with Pruitt-Inahara's shunt was performed in 17 cases with a perioperative neurological adverse event rate of 23.5%. In 13 cases limitations to shunting due to quick onset of coma and/or an unfavorable anatomy were encountered. In these 13 cases the open intervention was immediately converted into endovascular procedure. Technical success was achieved in all the converted to CAS cases (100%), with a perioperative neurological adverse event rate of 7.7% (P=0.35 between the two groups). No significant difference emerges comparing patient's survival between the cases treated with shunt and those converted into CAS. Conclusion. Nevertheless, the small dimension of this survey, immediate conversion to CAS resulted feasible with a lower risk of neurological adverse events if compared to CEA with shunt, and could be considered as an alternative to CEA when carotid shunt cannot be used safely.


PubMed | Peripheral Interventional Unit, Unit of Vascular Surgery, Radiology Unit and San Giovanni Of Dio Hospital
Type: Journal Article | Journal: European radiology | Year: 2016

To describe the hydrodynamic boost (HB) technique and report our preliminary results with this technique in the subintimal angioplasty of below-the-knee vessels.HB was used in 23 cases (14 males, mean age 7312years) of critical limb ischemia, with long chronic total occlusion of tibial arteries extended to the ankle level. The operator performs a manual injection of diluted contrast dye through a 4F catheter into the subintimal space, close to the patent true distal lumen, in order to achieve a tear in the intimal flap and a connection with the true lumen.In 19/23 (83%) cases, the HB was effective in creating a connection between the subintimal space and the true distal lumen and it was possible to advance a wire and to conclude the procedure. In 4/23 (17%) lesions, the HB failed and the procedure was successfully completed by retrograde approach. No major complications occurred. Mean length between catheter tip and re-entry point was 85mm.HB seems to be a feasible, safe and effective re-entry technique in distal below-the-knee vessels. This method represents an easy option for re-entry that extends the possibility of antegrade approach to obtain a successful revascularization. In subintimal angioplasty of below-the-knee vessel re-entry can represent a challenge. Inability to re-enter may determine the failure of the revascularization procedure. HB is a novel re-entry technique feasible in distal below-the-knee vessels. HB may increase the success rate of antegrade approach. In case of failure, retrograde approach remains feasible.


Lococo F.,Unit of Thoracic Surgery | Tusini N.,Unit of Vascular Surgery | Brandi L.,Unit of Thoracic Surgery | Leuzzi G.,IRCCS Instituto Nazionale Dei Tumori Foundation | And 3 more authors.
Vascular and Endovascular Surgery | Year: 2016

Right-side aortic arch is a rare congenital aortic anomaly occurring in 0.05% to 0.1% of the general population. Approximately, half of these cases may be associated with an aberrant left subclavian artery and occasionally with aneurysmatic change at its origin known as Kommerell diverticulum or aneurysm (KA). Herein we report a challenging case of a right-side aortic arch associated with KA incidentally observed in a 73-year-old male with metastatic lung cancer. After careful multidisciplinary discussion, a conservative strategy of care was successfully adopted. © The Author(s) 2016.


Scarcello E.,Unit of Vascular Surgery | Ferrari M.,Unit of Vascular Surgery | Rossi G.,CNR Institute of Clinical Physiology | Berchiolli R.,Unit of Vascular Surgery | And 3 more authors.
Annals of Vascular Surgery | Year: 2010

Background: In patients with ruptured abdominal aortic aneurysm (RAAA) and shock, the time lag between the onset of the symptoms due to RAAA and the presence of a full developed shock syndrome was evaluated to assess its prognostic meaning. This time lag was called time before shock (TBS). Methods: Ninety-four patients operated on between 2002 and 2007 have been retrospectively analyzed regarding TBS and the following parameters: presence of shock, severity of bleeding, age, comorbidities, and gender. According to TBS, on a 10-hour cutoff value, three groups of patients were distinguished: patients with TBS of 10 or less (short TBS), patients with TBS greater than 10 (long TBS), and patients without shock. The relationship of these variables with intraoperative and 30-day mortality was analyzed by both univariate and multivariate analyses. Results: In the univariate analysis, patients with short TBS presented with four-fold mortality compared to patients without shock (p=0.000), whereas the increase in mortality of the patients with long TBS was nonsignificant (p=0.448). The mortality in patients with shock (presence of shock) was 3.7 times higher than in patients without shock (p=0.001). The mortality related to massive bleeding was 3.7 times higher than that associated with moderate bleeding (p=0.001). An increased mortality with borderline significance level was observed in patients older than 75 years (p=0.052). The relationship of mortality to the presence of comorbidities and gender was not significant. In the multivariate analysis, the mortality among the patients with short TBS was clearly highest, after either massive or moderate bleeding. In the logistic model with TBS, the Wald test showed as significant both short TBS (p=0.001) and severity of bleeding (p=0.033) but not age (p=0.103) and long TBS (p=0.0401). The model with TBS presented a better performance than that with shock, showing higher sensitivity, higher values of Youden's J, and a greater proportion of the total variation in mortality. Through the model with TBS, two groups of patients (those 75 years or younger with massive bleeding and those older than 75 years with moderate bleeding), both with short TBS, presented with a high risk of death not predicted by the model with shock. Conclusion: TBS seems to complete the information given by the parameter "presence of shock," and its evaluation allows a more effective judgment of the risk of death, at emergency admission of patients with RAAA. © 2010.


Ferrer C.,Unit of Vascular Surgery | Cao P.,Unit of Vascular Surgery | De Rango P.,University of Perugia | Tshomba Y.,Vita-Salute San Raffaele University | And 4 more authors.
Journal of Vascular Surgery | Year: 2016

Objective The aim of this study was to investigate outcomes of patients treated with endovascular repair (ER) with the use of fenestrated and branched stent grafts or open surgery (OS) for thoracoabdominal aortic aneurysm (TAAA) in a current series of patients. Methods All TAAA patients undergoing repair at three centers between January 2007 and December 2014 were included in a prospective database. Patients were stratified according to treatment by ER or OS, and outcomes were compared using propensity score matching (1:1). Covariates included age, sex, aneurysm extent, hypertension, coronary disease, chronic pulmonary disease, diabetes, and renal function. The primary end points were mortality and paraplegia. Secondary end points included any spinal cord ischemia (SCI), renal and respiratory insufficiency, and a composite of these complications or death at 30 days. All-cause survival and freedom from reintervention were compared in the two groups. Results Of 341 patients, 84 (25%) underwent ER and 257 underwent OS (75%). After propensity score matching (65 patients per group), no significant differences were observed in rates of 30-day mortality (7.7% in ER and 6.2% in OS; P = 1) and paraplegia (9.2% and 10.8%; P = 1). Any SCI, renal insufficiency, and respiratory insufficiency were 12.3% and 20% (P =.34), 9.2% and 12.3% (P =.78), and 0% and 12.3% (P =.006) in ER and OS, respectively. The incidence of the composite end point was significantly lower in ER patients (18.5% in ER vs 36.0% in OS; P =.03). According to Kaplan-Meier estimates, all-cause survival at 24 months was 82.8% in ER and 84.9% in OS, with rates unchanged at 42 months (P =.9). Rates of freedom from reintervention were 91.0% vs 89.7% at 24 months and 80.0% vs 79.9% at 42 months in ER vs OS, respectively (P =.3). Conclusions A propensity score analysis in patients with TAAA undergoing repair suggests an early benefit from ER compared with OS with regard to the composite end point because of reduced 30-day respiratory complications. No significant differences were found in SCI and renal insufficiency at 30 days and in survival and reintervention rates at midterm. Copyright © by the 2016 Society for Vascular Surgery.


Verzini F.,University of Perugia | Biello A.,University of Perugia | Marucchini A.,University of Perugia | Parente B.,University of Perugia | And 2 more authors.
Journal of Vascular Surgery | Year: 2013

Visceral aneurysms are rare in the general population (<2%), and the most serious complication is represented by aneurysm rupture. The use of stent grafts to exclude visceral aneurysms is described in several reports but is reserved for patients with favorable anatomy. We report here on a hepatic artery pseudoaneurysm in a liver transplant patient and a patient with an aneurysmal vein graft degeneration of a renal bypass, both with no suitable proximal neck for standard stent grafting. Both patients were successfully treated with a custom-made aortic endograft with a single fenestration for the hepatic or renal artery, together with a visceral covered stent. Although initial results are promising, long-term follow-up is required to assess durability. © 2013 by the Society for Vascular Surgery. © 2013 by the Society for Vascular Surgery.


PubMed | Unit of Vascular Surgery, University of Ferrara, Unit of Nuclear Medicine, IRCCS of Neurosciences and Unit of Translational Surgery
Type: Journal Article | Journal: Journal of vascular surgery. Venous and lymphatic disorders | Year: 2016

Increased ventricle volume and brain hypoperfusion are linked to neurodegeneration. We hypothesized that in patients with restricted jugular flow, surgical restoration may reduce brain ventricle volume, because it should improve the pressure gradient, hence promoting cerebrospinal fluid reabsorption into the venous system.The effects of restoring the jugular flow were assessed by means of a validated echocardiography with color Doppler (ECD) protocol of flow quantification, magnetic resonance venography, and single-photon emission computed tomography combined with computed tomography (SPECT-CT). The main outcome measurement was the cerebral ventricle volume blindly assessed at SPECT-CT. Secondary outcomes were brain perfusion in the whole brain and in another 12 cerebral regions. The mean follow-up of the SPECT-CT and ECD parameters was 30 days. Patency rate was subsequently monitored by means of the same ECD protocol every 3 months.Among 56 patients (28 male and 28 female; mean age, 44 10 years) with ECD screening positive for chronic cerebrospinal venous insufficiency due to nonmobile jugular leaflets, 15 patients were excluded from the initial cohort because they did not meet the inclusion and exclusion criteria. Of the remaining 41 patients, 27 patients (14 male, 13female; mean age, 48 7 years) underwent endophlebectomy and autologous vein patch angioplasty. Omohyoid muscle section was performed when appropriate. The control group comprised 14 patients matched by age and gender (8 male, 6 female; mean age, 44 11 years) who were not treated. Comorbidity was multiple sclerosis without significant differences in relapsing remitting (RR) and secondary progressive (SP) clinical course among groups. In the control group, neither ECD nor SPECT-CT showed any significant changes at follow-up. On the contrary, in the group operated on, the collateral flow index went from 70% to 30% (P< .0003) thanks to improved flow through the internal jugular vein. Correspondingly, ventricle volume dramatically decreased in the treated group (from 34 14 cm(3) to 31 13 cm(3); P< .01). The effect was much more evident in the RR subgroup (P= .009), whereas in the SP subgroup, it was not significant. Perfusion was found to be improved in the surgical group with respect to controls, particularly in the occipital and parietal regions of the RR subgroup (P< .0001 and P= .017, respectively), but not in the SP subgroup. The probability of reducing ventricle size is increased by 13-fold (P< .03) when restoration of the jugular flow achieves a postoperative collateral flow index 20%. Finally, the 18-month patency rate was 74%.Fixing the flow in the jugulars in patients with chronic cerebrospinal venous insufficiency might significantly reduce brain ventricle volume and improve cerebral perfusion. These changes are more evident in patients in the earlier stages of neurodegenerative disease.


Rispoli P.,Unit of Vascular Surgery | Santovito D.,Unit of Vascular Surgery | Tallia C.,Unit of Vascular Surgery | Varetto G.,Unit of Vascular Surgery | And 2 more authors.
Journal of Vascular Surgery | Year: 2010

This report describes the case of a 60-year-old woman with a history of hysterectomy for myomas, totally asymptomatic, with incidental evidence of a pelvic intracaval mass extending to the right atrium. She underwent a staged procedure (sternothomic and abdominal) through a thoracolaparotomic approach in circulatory arrest and deep hypothermia. Using a one-stage surgical approach, we were able to withdraw one portion of the mass from the right atrium and another from the abdominal inferior vena cava, thus minimizing the risk of unexpected venous or atrial wall injury during surgical manipulation. © 2010 Society for Vascular Surgery.

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