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Background The management of type II endoleak causing sac enlargement continues to be a topic of debate. The purpose of this study was to examine and compare the outcomes between open surgical technique with sacotomy and suturing of the feeding vessels to interventional embolization in patients with aneurysm sac expansion after endovascular aneurysm repair (EVAR). Methods Inclusion criteria for intervention in patients with prior EVAR and type II endoleak were asymptomatic expanding aneurysm sac > 5 mm between 2 consecutive follow-up computed tomography angiography scans and symptomatic aneurysm sac expansion. Age, sex, comorbidities, clinical presentation, commercial type of endograft of prior EVAR, aneurysm sac increase, type of treatment, morbidity, mortality, and follow-up were also recorded. Results A total of 694 consecutive patients were operated with EVAR during the study period. Among them, 29 patients (4.2%) were presented with a type II endoleak that required reintervention. Ten patients (34.5%) were treated with embolization. We recorded a 50% technical success in the group of primary translumbar embolization and 67% in the group of intra-arterial embolization. Twenty-two patients were treated with laparotomy and open ligation of the culprit arteries causing the type II endoleak. Among them, 3 patients (13.6%) had been initially treated with unsuccessful embolization. Periprocedural intervention complications for the embolization group (10%, 1/10) included 1 psoas hematoma. On the contrary, complications after primary open ligation were 13.6% (3/22) and included 1 proximal dislocation treated with endograft explantation, 1 distal dislocation, and 1 limb ligation with femoral-femoral bypass which resulted in colonic ischemia and death (4.5%). Conclusions Open surgical repair with sacotomy and suturing of the feeding vessels appeared to have better outcome regarding the exclusion of the aneurysm but was associated with a higher incidence of severe complications and one related death. If these results are confirmed in larger series, endovascular approach should be the preferred treatment option.

Introduction To investigate the safety and efficacy of percutaneous stenting for the management of chronic ischemia caused by endograft limb occlusion following endovascular aortic aneurysm repair (EVAR). Methods This is a retrospective, single-center study investigating all patients who underwent percutaneous endovascular covered or bare metal stent placement for the management of intermittent claudication (IC) or critical limb ischemia following EVAR limb occlusion, between January 2010 and October 2017. Cases suffering from acute limb ischemia were treated surgically and were excluded from the analysis. Primary outcome measures were technical success and symptoms-free interval. Secondary outcome measures included clinically driven target-lesion reintervention (TLR)-free survival, primary patency, and complication rates. Results Of 29 limb occlusions, 11 limbs (11 patients; 100% male; mean age: 71.6 ± 6.9 years) were treated percutaneously and were included in the study. The majority suffered from IC (10/11; 90.9%) with a single case of rest pain. Technical success was obtained in 10 patients (90%). No major complications occurred. Mean follow-up time was 37.6 ± 25.7 months. Stent grafts were mainly used, while and in 2 cases (18.18%), only nitinol bare stents were deployed. According to Kaplan-Meier analysis, both symptoms-free interval and primary patency were 83.33% in up to 5 years follow-up. TLR-free survival was 100% at 5 years, as 2 cases of claudication relapse were managed conservatively. Conclusions Percutaneous stenting for the management chronic ischemia due to EVAR limb occlusion is feasible and safe, with satisfactory long-term outcomes. Careful patient selection warrants clinical success.

Angiosarcomas developing in nonfunctioning arteriovenous fistulas in renal transplant recipients are quite rare clinical entities with very poor prognosis. Herein we present a 60-year-old male who developed an angiosarcoma in a thrombosed radiocephalic fistula 6 years after renal transplantation. The patient presented with pain and swelling at the site of a previously asymptomatic fistula. The fistula was excised and diagnosis was made by histology. Despite radical surgery with an above-elbow amputation, the patient died of metastatic disease 6 months later.

Background Acute early carotid stent thrombosis (AcuteCST) is a rare complication after carotid artery stenting (CAS). The purpose of this retrospective study was to investigate the incidence, causes, and optimal management of AcuteCST. Methods Medical records of all patients undergoing CAS between 2008 and 2016 were retrospectively reviewed. The time of thrombosis, grade of stenosis, lesion side, preprocedural and postprocedural anticoagulants, causes, symptoms, treatment, recanalization, and outcome were reviewed. Results Overall, 674 patients were treated with CAS. Four cases of AcuteCST were identified (0.59%). In the first patient, the stent thrombosis was attributed to dissection caused by filter deployment within a distal internal carotid artery with 360° coiling. Notably, in 3 of the 4 cases of thrombosis a second overlapping stent had been deployed. In total, 41 patients of the cohort under investigation underwent overlapping stent deployment. The use of a second overlapping stent as a bail-out procedure due to dissection or malposition or due to long lesions was correlated with increased rate of thrombosis (3/41 [7.3%] vs. 1/633 [0.002%]). In 2 patients, carotid stents were thrombosed within 2 hr of the procedure. Endovascular thrombus aspiration and subsequent eversion carotid endarterectomy with stent explantation in the first patient and intrathrombus urokinase administration with thromboaspiration and additional stent placement in the second patient were followed. In the other 2 patients having their carotid stents thrombosed 3 and 4 days after the procedure, treatment with low weight molecular heparin and antiplatelet regimens was followed. Conclusions The use of overlapping stents in the carotid artery is a predisposing factor for AcuteCST. Prognostic factors of this potentially devastating complication are the initial clinical presentation expressing the grade of ischemic brain damage, the accurate and timely recognition of the thrombosis, and the prompt restoration of oxygenated blood flow into the viable tissue at risk of infarction.

Bilateral limb occlusion after endovascular aortic repair (EVAR) is relatively uncommon. The aim of this study was to investigate the incidence of bilateral endograft limb occlusion after EVAR and identify potential anatomical predictive factors of occurrence.A total of 579 patients underwent elective EVAR for abdominal aortic aneurysm between January 2010 and December 2015. All patients presenting with unilateral and bilateral occlusions were prospectively analyzed. A group of patients who underwent EVAR but did not present with endograft limb occlusion were matched for sex, age, and commercial type of endograft and were used as controls.Overall, 21 (3.6%) patients were complicated with unilateral endograft limb occlusion, whereas 8 (1.4%) of them presented with sequential (in different time) bilateral limb occlusion. We found that iliac artery angulation ≥60°, iliac perimeter calcification ≥50%, and endograft oversizing in the common iliac artery of more than 15% had the same impact and could equally result in limb occlusion. We coded the variables angle, calcification, and endograft limb oversizing of the common iliac artery with a score from 0 to 2 as follows: (1) 0: angle60° in both limbs, 1: angle ≥60° in one limb, 2: angle ≥60° in both limbs; (2) 0: calcification50%: in both limbs, 1: calcification ≥ 50%: in one limb, 2: calcification ≥ 50%: in both limbs; and (3) 0: endograft limb oversizing15%, 1: endograft limb oversizing ≥15% in one limb, 2: endograft limb oversizing ≥15% in both limbs. A composite variable, consisting of the sum of scoring in variables was analyzed, with a score from 0 to 6. Our study showed that it was the most probable to be in the control group when score in the composite variable was 0-3, it was the most probable to have unilateral limb occlusion when score was 4-5, and finally, it was the most probable to have bilateral limb occlusion when score in the composite variable was equal to 6.Our study evidenced that the highest probability for bilateral limb occlusion occurred when implantation of a more than 15% oversized endograft in iliac arteries with iliac artery angulation ≥60° and iliac perimeter calcification ≥50% was present in both iliac arteries. It is therefore clear that limb occlusion requires the synergistic effect and interaction of bilateral multiple thrombogenic components in the iliac artery before it is manifested.

Type IIIb endoleak usually occurs years after the initial endograft implantation, and the cause is the chronic fatigue of the endograft. This rare case describes a type IIIb endoleak, appearing immediately after deployment of a new generation low-profile stentgraft and highlights the diagnostic and treatment challenges associated with the type IIIb endoleak. A 74-year-old man underwent elective EVAR for an infrarenal abdominal aortic aneurysm. A type IIIb endoleak near to the flow divider due to a fabric defect was diagnosed. The endoleak was successfully treated by endovascular positioning of a converter stent graft followed by the occlusion of the left limb with an iliac occluder and a femoro-femoral crossover bypass surgery. The ultrasound scan after 4 weeks showed no sign of endoleak. Occurrence of a type IIIb endoleak immediately after deployment is extremely rare. Based on the convenience of the intraoperative procedure and the anatomic characteristics of the aneurysm, we assume that the fabric defect might have occurred during loading of the endograft and subsequent confinement in the delivery catheter. We cannot definitely rule out the possibility of fabric damage induced by low-pressure balloon instrumentation. In case of a suspicion of a type IIIb endoleak, bilateral balloon occlusion of both limbs followed by antergrade aortography will help to identify the leak. In case the defect is near to the flow divider, aortouniliac grafting followed by femoro-femoral crossover bypass surgery represents an alternative option to conversion to open surgical repair.

Background High-grade stenoses of both common (CCA) and the internal (ICA) carotid arteries are rare and represent a therapeutic dilemma for the treating physician. The aim of this article is to present our experience with fully endovascular repair of those lesions. Methods Between January 2011 and December 2012, 5 patients (all male, age 73.6 years) with concomitant CCA and ICA stenoses were treated endovascularly. All patients were asymptomatic. The lesions involved the left carotid in 3 and the right carotid in 2 cases. Common carotid artery stenosis was located at the ostium (1 patient), the middle (3 patients) and the distal segment (1 patient) of the CCA. In 3 cases, CCA stenting was initially performed followed by ICA treatment, whereas in the remaining 2, ICA stenting preceded CCA stenting. A filter embolic protection device was used in 2 cases. Results All procedures were successfully completed. Technical success rate was 100%. Mortality rate was 0%. One patient experienced transient neurologic complication. An 82-year-old who underwent left mid-CCA and ICA stenosis without embolic protection device suffered a transient ischemic attack with dysarthria lasting for a few minutes. A 73-year-old patient with left CCA and ICA stenosis and occlusion of the right ICA who underwent stenting under cerebral protection experienced symptoms consistent with cerebral hyperperfusion. Patients were followed up for a mean of 6 months. No neurologic complications or stent restenosis were detected. Conclusions Angioplasty and stenting is a technically feasible method for the treatment of concomitant CCA and ICA stenosis with acceptable short- and mid-term results.