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The aim of the present study was to evaluate the impact of the aortic bifurcation (AB) morphological characteristics, analyzed on computed tomography angiography (CTA), on outcomes of patients with abdominal aortic aneurysms (AAAs), treated by endovascular aneurysm repair (EVAR) in a single-center experience. A retrospective analysis was conducted using a prospectively collected database. Morphological features considered as potentially impacting outcomes were maximum AB diameter (ABmax), minimum diameter (ABmin), mean diameter (ABaverage), AB area (ABarea), and AB calcification (ABcalcification) and thrombosis (ABthrombosis). Outcome measures were perioperative, 30-day, and midterm AAA-related reinterventions and all-cause mortalities. Investigators reviewed 306 preoperative CTA scans. Maximum aortic diameter was 51.4 ± 12.4 mm (range 40–110), and mean ABmax was 24.2 ± 8.8 mm (range 10–60), ABmin 17.0 ± 5.4 mm (range 4–40), ABaverage 20.6 ± 6.5 mm (range 9–47.5), and ABarea 35.2 ± 24.2 mm2 (range 6–176). ABcalcification ≥ 50% was present in 63 patients (20.6%), and ABthrombosis ≥ 50% in 102 patients (33.3%). Technical success was obtained in all cases, without perioperative reintervention or death. At 30-day follow-up, the reintervention rate was 3.3%, and mortality rate was 1.3%. At a mean follow-up period of 35 ± 28.6 (range, 1–72) months, reintervention and mortality rates were 6.5 and 4.9%, respectively. None of the analyzed thresholds were predictive of adverse outcomes. At multivariate analysis, association of a narrowed AB with severe calcification of the distal aorta showed a significant differences in terms of reinterventions (p = 0.009). Our limited experience seems to reveal that a cutoff of ≤ 20 mm for AB diameter, as in current guidelines, is ineffective in predicting outcomes after EVAR. more...

Acute limb ischemia (ALI) is a pathological condition resulting from a sudden blood interruption (or, at least, from an important reduction in flow) limiting tissues’ survival. ALI is always a serious event requiring immediate diagnosis and treatment, also considering the high associated amputation risk. The most frequent causes of acute limb ischemia are embolism, thrombosis, and trauma. Clinical findings are grouped together in a series mnemonic note as “6P of Pratt”: pain, pallor, pulselessness, poikilothermia, paresthesia, and paralysis. Those in concert with duplex ultrasound assume a primary and crucial role in diagnostic and preoperative evaluation of ALI patients. Treatment for ALI largely depends on the clinical presentation according to Rutherford’s classification. When indication for surgery is posed, several open, endovascular, and hybrid procedures are developed to restore blood flow in acute patients. more...

To report a case of pararenal aortic aneurysm (PAAA) with narrowed iliac arteries treated by the chimney technique combined with the INCRAFT

Purpose: Hypogastric artery (HA) revascularization during endovascular aneurysm repair (EVAR) is still open to debate. Moreover, exclusion-related complication rates reported in literature are not negligible. The aim of this study is to present and analyze the outcomes in patients undergoing EVAR with exclusion of 1 or both HAs at our academic center. Methods: We retrospectively reviewed our results in patients submitted to EVAR and needing HA exclusion, in terms of perioperative (30-day) and follow-up rates of intestinal and spinal cord ischemia, buttock claudication, buttock skin necrosis, and sexual dysfunction. Results: From January 2008 to December 2014, a total of 527 patients underwent elective standard infrarenal EVAR; among those 104 (19.7%) had iliac involvement needing HA exclusion. In 73 patients with unilateral iliac involvement (70.1%, group UH), many single HAs were excluded. Thirty-one patients (29.9%) had bilateral iliac involvement (group BH), of which 16 (51.6%) had 1 HA excluded with revascularization of the contralateral one (group BHR); in the remaining 15 patients (48.4%) both HAs were excluded (group BHE). No 30-day or follow-up aneurysm-related mortality, intestinal, or spinal cord ischemia were recorded. At 30 days, skin necrosis was observed in 2 patients. Buttock claudication and sexual dysfunction rates were significantly greater in group BHE than in group BHR ( P < .05). At a mean 18.6 months follow-up (range: 4-47), buttock claudication and sexual dysfunction rates in group BHE were persistently higher than that in groups UH and BHR ( P < .05); HA coil embolization was significantly associated with buttock claudication and sexual dysfunction ( P < .05). Conclusions: Whenever anatomically feasible, at least 1 HA should be salvaged in case of bilateral involvement. In case of unilateral HA exclusion, the rate of complications is not negligible. Coil embolization is related to a higher complication rate. more...

To report a case of pararenal aortic aneurysm (PAAA) with narrowed iliac arteries treated by the chimney technique combined with the INCRAFT® AAA stent graft system. A 75-year-old man was diagnosed with a 55-mm PAAA. Patient was judged unfit for open repair and for standard endovascular aneurysm repair (EVAR) due to its clinical and anatomical requirements. Custom-made fenestrated device (FEVAR) was excluded due to the presence of narrowed and heavily calcified iliac axes. Consequently, patient underwent auspicious endovascular aneurysm repair with the INCRAFT System and chimney grafts in the superior mesenteric artery and both renal arteries. At 12 months' follow-up, patient was in good clinical condition, with preserved renal function. Computed tomographic angiography revealed inceptive shrinkage of the aneurysm with patency of aortic and visceral grafts even in the presence of a low-flow type Ia endoleak. Chimney grafts (CGs) combined with the low-profile INCRAFT System seem to be feasible for treating PAAA, in high-risk patients unfit for standard EVAR or FEVAR devices. more...

All patients (n 1⁄4 1177) Wound (0-3) 1.1 (0.9-1.3) 1.7 (1.3-2.3) 1.2 (1.0-1.4) Ischemia (1-3) 1.5 (1.2-1.8) 3.5 (2.0-6.5) 1.2 (0.9-1.4) Infection (0 3) 1.2 (1.0 1.3) 1.7 (1.3-2.1) 1.2 (0.9-1.4) Composite (2-9) 1.2 (1.1-1.2) 1.8 (1.5-2.0) 1.2 (1.0-1.3) Mean (0-3) 1.4 (1.2-1.6) 4.5 (3.1-6.5) 1.2 (1.0-1.5) Clinical stage (1-4) 1.1 (0.9-1.3) 2.2 (1.6-3.1) 1.1(0.9-1.2) Bypass only (n 1⁄4 592) Wound (0-3) 1.3 (1.1-1.5) 1.6 (1.2-2.3) 1.3 (1.0-1.6) Laura Capoccia, Maria Antonietta Panico, DaniloMenna, Pasqualino Sirignano, Wassim Mansour, Nunzio Montelione, Chiara Pranteda, Martina Formiconi, Francesco Speziale. “Sapienza” University of Rome, Vascular and Endovascular Surgery Division, Department of Surgery “Paride Stefanini”, Policlinico Umberto I, “Sapienza” University of Rome, Roma, Italy; Maria Antonietta Panico, Vascular and Endovascular Surgery Division, Rome, Italy; Danilo Menna, Vascula and Endovascular Surgery Division, Rome, Italy; Policlinico Umberto I, Rome, Italy more...