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Objective: In the present study, we have described the incidence, risk factors, and outcomes of treatment of limb occlusion for patients who had undergone treatment of complex thoracoabdominal aortic aneurysms with the fenestrated Anaconda endograft (Terumo Aortic, Inchinnan, UK). Methods: Between June 2010 and May 2018, 335 patients had undergone elective fenestrated aortic aneurysm repair at 11 participating centers using the fenestrated Anaconda endograft with a median follow-up of 14.3 months (interquartile range, 27.4 months). The primary outcome measure was freedom from limb occlusion. The secondary outcome measures were freedom from limb-related reintervention, secondary patency, and the risk factors associated with limb occlusion. Results: Of the 335 patients, 30 (9.0%) had presented with limb occlusion during follow-up with a freedom from limb occlusion rate of 98.5%, 91.2%, and 81.7% at 30 days and 1 and 5 years, respectively. In 87% of the cases, no obvious cause for limb occlusion was documented. Primary occlusion had occurred within 30 days in 36.7% and within 1 year in 80.0%. Of the 30 patients, 23 (77%) had undergone an occlusion-related reintervention and 7 (23.3%) had been treated conservatively. The freedom from limb occlusion-related reintervention at 30 days and 1 and 5 years was 97.8%, 93.2%, and 88.6%, respectively. Secondary patency was 91.3% after 1 month and 86.2% after 1 and 5 years. Female sex (odds ratio [OR], 3.27; 95% confidence interval [CI], 1.28-8.34; P =.01) was a statistically significant predictor for limb occlusion. A greater proportion of thrombus in the aneurysm sac appeared to be protective for limb occlusion (0% vs 50%: OR, 0.08; 95% CI, 0.02-0.38; P =.00), as did iliac angulation (OR, 0.99; 95% CI, 0.98-1.00; P =.04). Conclusions: Limb occlusion remains a significant impediment of endograft durability for patients treated with the fenestrated Anaconda endograft, especially for female patients. In contrast, a high aneurysmal thrombus load and a high degree of iliac angulation appeared to be protective for limb occlusion, for which no obvious cause could be identified.

Objective: The objective of this study was to investigate the feasibility of a specific custom-made fenestrated aortic cuff in the treatment of complex abdominal aortic aneurysms (AAAs).Methods: Between 2013 and 2016, a total of 57 custom-made Fenestrated Anaconda (Vascutek, Inchinnan, Scotland, UK) aortic cuffs were placed in 38 centers worldwide. All centers were invited to participate in this retrospective analysis. Postoperative and follow-up data included the presence of adverse events, necessity for reintervention, and renal function.Results: Fifteen clinics participated, leading to 29 cases. Median age at operation was 74 years (interquartile range [IQR], 71-78 years); five patients were female. Two patients were treated for a para-anastomotic AAA after open AAA repair, 19 patients were treated because of a complicated course after primary endovascular AAA repair, and 8 cases were primary procedures for AAA. A total of 76 fenestrations (mean, 2.6 per case) were used. Four patients needed seven adjunctive procedures. Two patients underwent conversion, one because of a dissection of the superior mesenteric artery and one because of perforation of a renal artery. Median operation time was 225 minutes (IQR, 150-260 minutes); median blood loss, 200 mL (IQR, 100-500 mL); and median contrast volume, 150 mL (IQR, 92-260 mL). Primary technical success was achieved in 86% and secondary technical success in 93%. The 30-day morbidity was 7 of 29 with amortality rate of 4 of 29. Estimated glomerular filtration rate remained unchanged before and after surgery (76 to 77 mL/min/m(2)). Between preoperative and median follow-up of 11 months, estimated glomerular filtration rate was reduced statistically significantly (76 to 63 mL/min/m(2)). During follow-up, 9 cases had an increase in aneurysm sac diameter (5 cases > 5 mm); 14 cases had a stable or decreased aneurysm sac diameter; and in 2 cases, no aneurysm size was reported. No type I endoleak was reported, and two cases with a type III endoleak were treated by endovascular means during follow-up. Survival, reintervention-free survival, and target vessel patency at 1 year were 81% +/- 8%, 75% +/- 9%, and 99% +/- 1%, respectively. After 2 years, these numbers were 81% +/- 8%, 67% +/- 11%, and 88% +/- 6%, respectively. During follow-up, the two patients with a type III endoleak needed endograft-related reinterventions.Conclusions: Treatment with this specific custom-made fenestrated aortic cuff is feasible after complicated previous (endovascular) aortic repair or in complex AAAs. The complexity of certain AAA cases is underlined in this study, and the Fenestrated Anaconda aortic cuff is a valid option in selected cases in which few treatment options are left.

Background: Isolated iliac artery aneurysms (IAAs), accounting for 2% to 7% of all abdominal aneurysms, are often treated with the use of iliac branched endografts. Although outside the manufacturer's instructions for use, iliac branched devices can be used solely, without the adjunctive placement of an endovascular aneurysm repair device, for the treatment of an isolated IAA. In the present study, we have described the outcomes of the use of the Gore iliac branched endoprosthesis (IBE; W.L. Gore & Associates, Flagstaff, Ariz), without the support of an infrarenal endovascular aneurysm repair device, for the exclusion of an isolated IAA. The present study was an international multicenter retrospective cohort analysis. Methods: All the patients who had undergone treatment with a solitary IBE for IAA exclusion from January 11, 2013 to December 31, 2018 were retrospectively reviewed. The primary outcome was technical success. The secondary outcomes included mortality, intraoperative and postoperative complications, and reintervention. Results: A total of 18 European and American centers participated, with a total of 51 patients in whom 54 IAAs were excluded. The technical success rate was 94.1%, with an assisted technical success rate of 96.1%. No 30-day mortality occurred, with 98.1% patency of the internal and external iliac artery found at 24 months of follow-up. At 24 months of follow-up, 81.5% of the patients were free of complications and 90% were free of a secondary intervention. Conclusions: Treatment with a solitary IBE is a safe and, at midterm, an effective treatment strategy for selected patients with a solitary IAA.

Objective: To date, information on the fenestrated Anaconda endograft is limited to case series with a small sample size. This study was performed to assess the technical and clinical outcome of this device in a large international case series. Methods: All worldwide centers having treated more than 15 complex abdominal aortic aneurysms (AAA) or type IV thor- acoabdominal aortic aneurysm patients with the fenestrated Anaconda endograft were approached. Main outcome pa- rameters were procedural technical success, postoperative and follow-up clinical outcome for endoleaks, target vessel patency, reintervention rate, and patient survival. Results: Three hundred thirty-five consecutive cases treated between June 2010 and May 2018 in 11 sites were included. Patients were treated for a short neck infrarenal (n = 98), juxtarenal (n =191), suprarenal AAA (n = 27), or type IV thoracoabdominal aortic aneurysm (n =19). Mean age was 73.6 ? 4.6 years (292 male). Endografts contained a total of 920 fenestrations, with a mean of 2.7 ? 0.8 fenestrations per case. Technical success was 88.4% (primary, 82.7%; assisted primary 5.7%). In 6.9% of cases, a pro- cedural type IA endoleak was observed, spontaneously disappearing in 82.6% during early follow-up. The development of a type IA endoleak was associated with greater neck angulation (odds ratio [OR], 0.94; P = .01), three fenestrations (OR, 42.7; P = .01) and the presence of augmented proximal rings (OR, 0.17; P = .03). Median follow-up was 1.2 years (interquartile range, 0.4-2.6). The mean estimated glomerular filtration rate deteriorated from 67.6 ? 19.3 mL/min/1.73 m 2 preoperatively to 59.3 ? 22.7 mL/min/ 1.73 m 2 at latest follow-up ( P = .00). The freedom from AAA growth were 97.9 ? 0.9% (n =190) and 86.4 ? 3.0% (n = 68), with a freedom from AAA rupture of 99.7 ? 0.3% (n = 191) and 99.1 ? 0.7% (n = 68), at 1 and 3 years, respectively. The endoleak-free survival, excluding spontaneously resolved procedural endoleaks, at 1 and 3 years was 73.4 ? 2.6 (n = 143) and 65.6 ? 3.4% (n = 45), respectively. The target vessel patency at one and three years were 96.4 ? 0.7% (n = 493) and 92.7 ? 1.4% (n = 156), respectively. A total of 75 reinterventions were done in 64 cases (19.1%), of which 25 cases for an endoleak. The reintervention-free survival at 1 and 3 years were 83.6 ? 2.2% (n = 190) and 71.0 ? 3.7% (n = 68), respectively. No deaths during procedure, extending within 24 hours postoperatively, were observed. Within 30 days 14 patients (4.2%) died and during follow-up another 39 patients (11.6%) died. Three deaths were considered AAA related (one rupture, one endograft infection, and one bilateral renal artery occlusion). The estimated cumulative survival at 1 and 3 years were 89.8 ? 1.8% (n =191) and 79.2 ? 3.0% (n = 68), respectively. Conclusions: The custom-made fenestrated Anaconda endograft is a valuable option for the treatment of a complex AAA. A procedural type IA endoleak is seen relatively frequently, but spontaneously resolves in most cases. (J Vasc Surg 2020;72:25-35.)

Objective: The use of self-expanding stent grafts for treatment of popliteal artery aneurysms (PAA) is a matter of debate, although several studies have shown similar results compared with open surgery. In recent years, a new generation stent graft, with heparin-bonding technology, became available. The aim of this study is to present the results of endovascular PAA repair with heparin-bonded stent grafts.Methods: Data on all patients with PAA treated with a heparin-bonded polytetrafluoroethylene (ePTFE) stent graft between April 2009 and March 2014 were gathered in a database and retrospectively analyzed. Data were collected from four participating hospitals. Standard follow-up consisted of clinical assessment, and duplex ultrasound at 6 weeks, 6 months, 12 months, and annually thereafter. The primary endpoint of the study was primary patency. Secondary endpoints were primary-assisted and secondary patency and limb salvage rate.Results: A total of 72 PAA was treated in 70 patients. Mean age was 71.2 +/- 8.5 years and 93% were male (n = 65). The majority of PAA were asymptomatic (78%). Sixteen cases (22%) had a symptomatic PAA, of which seven (44%) presented with acute ischemia. Early postoperative complications occurred in two patients (3%). Median follow-up was 13 months (range 0-63 months). Primary patency rate at 1 year was 83% and after 3 years 69%; primary assisted patency rate was 87% at 1 year and 74% after 3 years. Secondary patency rate was 88% and 76% at 1 and 3 years, respectively. There were no amputations during follow-up.Conclusion: Endovascular treatment of PAA with heparin-bonded stent grafts is a safe treatment option with good early and mid-term patency rates comparable with open repair using the great saphenous vein. (C) 2016 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.

Objective: In this study, we analyzed the procedural success and early outcome of endovascular treatment of a multicenter cohort of patients with common iliac artery (CIA) aneurysms treated with the new GORE EXCLUDER (W. L. Gore & Associates, Flagstaff, Ariz) iliac branch endoprosthesis (IBE).Methods: A retrospective cohort analysis was performed in 13 sites in The Netherlands. Anatomic, demographic, procedural, and follow-up data were assessed from hospital records.Results: From November 2013 to December 2014, 51 CIA aneurysms were treated with an IBE in 46 patients. The median diameter of the treated aneurysm was 40.5 (range, 25.0-90.0) mm. The mean procedural time was 198 +/- 56 minutes. All but one implantation were successful; two type Ib endoleaks were noticed, resulting in a procedural success rate of 93.5%. The two type Ib endoleaks spontaneously disappeared at 30 days. There was no 30-day mortality. Ipsilateral buttock claudication was present in only two cases at 30 days and disappeared during follow-up. The incidence of reported erectile dysfunction was low and severe ischemic complications were absent. After a mean follow-up of 6 months, data on 17 treated aneurysms were available. Two showed a stable diameter, whereas 15 showed a mean decrease of 3.9 +/- 2.2 mm (P Conclusions: The use of the GORE EXCLUDER IBE device for CIA aneurysms is related to high procedural success, high patency rates, and low reintervention rates at short-term follow-up. Prospective data with longer follow-up are awaited to establish the role of the device in the treatment algorithm of CIA aneurysms.

Objective: In this study the first results are presented of a new endovascular technique using covered stents to reconstruct the aortic bifurcation in patients with aortoiliac occlusive disease. With the "Covered Endovascular Reconstruction of the Aortic Bifurcation" (CERAB) technique, the anatomy and physiology of the aortic bifurcation is mimicked.Material and methods: Between 2009 and March 2014, 103 patients (51 male, 52 female) suffering from obstructive lesions at the level of the aortic bifurcation were treated with CERAB in two clinics. The median age was 61 years (range 36-85 years). Lesion morphology was evaluated by CT angiography. Six TASC-II B lesions, nine TASC-II C lesions, and 88 TASC-II D lesions were treated. Follow up was a median 12 months (range 0-49 months) and consisted of clinical examination, ankle brachial indices, and duplex ultrasound examination.Results: Technical success was obtained in 98 procedures (95.1%). In five cases lesions could not be recanalized. Primary patency was 87.3% at 1 year and 82.3% at 2 years, while secondary patency was 95.0% at 1 year and 95.0% at 2 years. Mean ankle brachial indices improved significantly from 0.64 +/- 0.21 before to 0.91 +/- 014, after the procedure (p Conclusions: The CERAB technique appears to be a safe and feasible alternative to open surgical reconstruction of the aortic bifurcation in complex occlusive disease. Comparative studies with the current gold standards are indicated. (C) 2015 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.

Background: A relationship between post-surgical adhesion formation and peritoneal tumour implantation has been proposed. Hyaluronan (HA)-based agents reduce adhesion formation, but the effect on peritoneal tumour is not established. This study investigated the influence of a HA-containing agent on intraperitoneal tumour in an experimental model. Methods: 66 Balb/c mice underwent laparotomy and damage was inflicted to the parietal peritoneum. The animals were randomized into five groups. Groups 1 and 2 received HA-carboxymethylcellulose bioresorbable membrane and no treatment, respectively. Mice in groups 3–5 were injected intraperitoneally with 105 colon 26-B cells after the laparotomy. Treatment consisted of HA membrane, no HA agent and placement of HA membrane on the non-traumatized peritoneal wall, respectively. Animals were killed after 14 days; adhesions were scored in groups 1 and 2, and the tumour mass in groups 3–5. 45 Wag/Rij rats underwent the same procedures and treatment as mice in groups 3–5. In rats, 106 CC-531 cells were injected. Rats were killed after 3 weeks and the tumour mass was scored. Results: HA membrane resulted in a significant reduction of adhesions, but had no major effect on the intraperitoneal tumour mass in mice and rats. Conclusion: HA-carboxymethylcellulose bioresorbable membrane has no major effect on intraperitoneal tumour implantation and growth in an experimental model.

BackgroundArterial insufficiency is rarely caused by isolated infrarenal aortic occlusive lesions. Endovascular treatment options include plain balloon angioplasty and bare metal stent placement. In this study the feasibility and efficacy of polytetrafluoroethylene (PTFE) covered balloon expandable stents were evaluated.Material and methodsConsecutive patients from two centers were prospectively collected in a database and retrospectively analyzed. Results were evaluated by clinical examination, ankle-brachial indices (ABI), duplex ultrasound, and plain abdominal radiography.ResultsThirty-six consecutive patients were treated between November 2008 and June 2013. Indication for treatment was Rutherford 3 (n = 29), 4 (n = 3), and 5 (n = 4). Technical success was always achieved and there were no distal embolizations or vessel wall ruptures. The median follow-up was 22 months (range 0–60). All patients improved clinically and the ABI increased significantly from 0.73 ± 0.18 to 1.01 ± 0.14 (p

Item does not contain fulltext Redo femoropopliteal bypass surgery is associated with increased morbidity and related to a poorer outcome than primary procedures. Endografts might provide an alternative, avoiding dissection of a previously operated groin. Patients treated with a polytetrafluoroethylene-covered stents for superficial femoral artery occlusive disease between February 2009 and September 2011 were prospectively gathered. Demographics, clinical status, procedural aspects, and follow-up were retrieved. Seventy-four patients were included of which 5 (7%) were treated before with a femoropopliteal bypass. Indication for intervention was Rutherford category 3 in all patients and the median ankle-brachial index (ABI) was 0.68. Technical success was achieved in all cases. The postoperative course was uneventful in all and the ABI increased to 0.95. After a follow-up period of 18 months, 4 of 5 endografts remained patent. The use of endografts after failed femoropopliteal bypass surgery is feasible and safe and could be used to avoid or minimize a difficult and hazardous dissection of a previously operated area. 01 mei 2012

Background This study assessed the peritoneal fibrinolytic response during the first week after colonic surgery in rats with and without bacterial peritonitis, and possible modulation of the response by two hyaluronan-based antiadhesive agents. Methods A colonic anastomosis was constructed in 90 male Wistar rats. Peritonitis was induced in another 108 rats and a colonic anastomosis was constructed after 24 h. Rats in both groups were randomized into an untreated group or one of two groups treated with hyaluronan-based agents. One-third of each group was killed at each of days 1, 3 and 7 after operation, and tissue plasminogen activator (tPA) antigen and activity were measured in peritoneal biopsies. Results One day after colonic surgery in normal rats, tPA antigen concentration was significantly (P < 0·005) increased, whereas tPA activity levels were normal. By day 3 after operation tPA antigen had returned to baseline values while tPA activity was significantly increased (P < 0·05). One day after inducing peritonitis tPA antigen was significantly increased (P < 0·001), while tPA activity was significantly reduced (P < 0·05). Three and seven days after colonic surgery in rats with peritonitis tPA activity was increased (P < 0·001) while tPA antigen had returned to baseline values. Neither of the hyaluronan-based agents affected peritoneal tPA antigen levels or activity after colonic surgery. Conclusion Both abdominal surgery and infection caused an early increase in peritoneal tPA antigen levels, followed by an increase in tPA activity. Peritonitis severely depressed early tPA activity. Application of hyaluronan-based agents did not affect the peritoneal fibrinolytic response to surgery and/or infection.

Background Hyaluronic acid (HA) agents reduce postsurgical adhesion formation. The effect of their perioperative administration on early anastomotic healing is unknown. This study investigated the influence of two HA-containing agents on the development of strength in colonic anastomosis during the first postoperative week, both in normal rats and in rats with bacterial peritonitis. Methods In 90 male Wistar rats a 1-cm segment was resected from the descending colon and an end-to-end anastomosis was constructed. In 108 rats a bacterial peritonitis was induced using caecal ligation and puncture (CLP). Some 24 h after CLP the abdomen was reopened, the caecum was taken out and, after resection of a 1-cm segment, an anastomosis was made. Animals in both groups were randomized to receive either an HA–carboxymethylcellulose (CMC) bioresorbable membrane, 0·4 per cent HA solution or no treatment. One-third of each group was killed at day 1, 3 and 7 after operation. Cultures were taken from the abdominal cavity for microbiological analysis in half of the animals. Subsequently, both bursting pressure and breaking strength were determined as parameters for anastomotic strength. Results No differences in anastomotic bursting pressure or breaking strength were found between the experimental groups and their controls. In addition, there was no significant difference in the number of bacteria cultured from the abdominal cavity between rats treated with HA and controls. Conclusion Neither HA-CMC bioresorbable membrane nor 0·4 per cent HA solution interferes with the development of early anastomotic strength in the colon, and can therefore be safely used to prevent intra-abdominal adhesion formation after performing bowel anastomosis.

Evaluating the influence of sodium hyaluronate on the proliferation rate of attached and nonattached human peritoneal mesothelial cells to elucidate whether this is a possible mechanism of action in peritoneal tissue repair.Controlled laboratory experiment.A university hospital.Five patients undergoing colorectal surgery for noninfectious reasons.Human peritoneal mesothelial cells were harvested from patients undergoing a laparotomy for noninfectious reasons. Cells, both nonattached and attached, were incubated for 4 and 24 hours with different concentrations of sodium hyaluronate. Thereafter, the cell proliferation rate was measured by XTT (2,3-bis-(2-methoxy-4-nitro-5-sulfophenyl)-2H-tetrazolium-5-car boxanilide) colorimetric assay. To mimic peritoneal injury, the cells were exposed to tumor necrosis factor alpha and/or lipopolysaccharide and were incubated immediately or after 24 hours of exposure to 0% or 0.2% sodium hyaluronate. Afterward, the cell proliferation rate was measured.Proliferation rate measured by XTT assay.Sodium hyaluronate significantly increased the proliferation rate of mesothelial cells, both in a nonattached (P.005) and attached (P.001) state. Exposure of the mesothelial cells to tumor necrosis factor alpha and/or lipopolysaccharide diminished the cells' proliferation rate. However, incubation of these exposed cells with 0.2% sodium hyaluronate significantly increased the proliferation rate, regardless of whether the sodium hyaluronate was added immediately (P.001) or after 24 hours (P.001).Sodium hyaluronate increases the proliferation rate of human peritoneal mesothelial cells, both attached and nonattached, under normal conditions and after stimulation with tumor necrosis factor alpha and/or lipopolysaccharide.

OBJECTIVE: To evaluate the accuracy of technetium-99m-labeled polyethylene glycol-coated liposomes (99mTc-PEG liposomes) and technetium-99m-labeled nonspecific human immunoglobulin G (99mTc-HYNIC IgG) for the scintigraphic detection of experimental intraabdominal abscesses in comparison with that of a standard agent, gallium-67 citrate. BACKGROUND: Scintigraphic imaging techniques can be very useful for the rapid and accurate localization of intraabdominal abscesses. Two newly developed radiolabeled agents, 99mTc-PEG liposomes and 99mTc-HYNIC IgG, have shown to be excellent agents for imaging experimental focal infection, but have not yet been studied in the detection of abdominal abscesses. METHODS: Intraabdominal abscesses were induced in 42 rats using the cecal ligation and puncture technique. Seven days later, randomized groups of rats received 99mTc-PEG liposomes, 99mTc-HYNIC IgG, or 67Ga citrate intravenously. The rats were imaged up to 24 hours after the injection. The biodistribution of the radiolabel was determined by counting dissected tissues ex vivo. Macroscopic intraabdominal abnormalities and focal uptake on the images were independently scored on a semiquantitative scale. RESULTS: 99mTc-PEG liposomes provided the earliest scintigraphic visualization of the abscess (as soon as 2 hours after the injection vs. 4 hours for the other two agents). Liposomes, IgG, and gallium all showed similarly high absolute uptake in the abscess. Focal uptake of liposomes and gallium correlated best with the extent of the macroscopic abnormalities. CONCLUSIONS: 99mTc-PEG liposomes and 99mTc-HYNIC IgG performed at least as well as the standard agent, 67Ga citrate, in the detection of experimental intraabdominal abscesses, with obvious advantages such as lower radiation exposure and more favorable physical properties. Of the two technetium agents, the liposomes seemed to be superior, providing the earliest diagnostic image and the best correlation with the inflammatory abnormalities. In addition, the preferential localization of radiolabeled PEG liposomes holds promise for targeted delivery of liposome-encapsulated drugs.

Background This study aimed to measure the fibrinolytic response, which plays a role in adhesion and abscess formation, of the parietal peritoneum to surgery in the presence and absence of bacterial peritonitis. Methods In 48 male Wistar rats bacterial peritonitis was induced using caecal ligation and puncture (CLP). Some 24 h after CLP (day 0), 12 rats were killed and biopsies were taken from the parietal peritoneum. The remaining 36 rats were reoperated whereby the ligated caecum was resected followed by resection of a 1-cm segment of the descending colon and end-to-end anastomosis. Thirty additional rats underwent resection of a 1-cm segment and anastomosis of the descending colon without any previous procedure. One-third of the rats were killed on days 1, 3 and 7 after anastomosing the colon, and biopsies were taken from the parietal peritoneum. From ten untreated rats, biopsies were taken for measurement of baseline levels. All biopsies were homogenized and tissue plasminogen activator (tPA) activity was measured using an enzyme-linked immunosorbent assay. Results Some 24 h after inducing peritonitis (day 0), tPA activity was significantly (P < 0·0001) decreased compared with baseline levels. One day after anastomosis in rats with peritonitis, tPA activity was in the same range as baseline values, while tPA activity was significantly increased on days 3 and 7 after anastomosis, in comparison to baseline levels (P = 0·0002). There was no significant difference in tPA activity compared with baseline levels 1, 3 and 7 days after anastomosing colon in normal rats. Conclusion In rats with bacterial peritonitis, tPA activity in the parietal peritoneum was depressed after 24 h; 24–48 h after inducing peritonitis, tPA activity increased, reaching supranormal levels at days 3–7. Surgery alone does not influence tPA activity of the parietal peritoneum.