Early Occlusion Research Articles

Long-term outcomes of endovenous laser ablation, n-butyl cyanoacrylate, and radiofrequency ablation for treatment of chronic venous insufficiency

BackgroundIn the present retrospective, single-center study, we evaluated the long-term effectiveness and reliability of endovenous laser ablation (EVLA), endovenous n-butyl cyanoacrylate (NBCA) application, and radiofrequency ablation (RFA) in the management of chronic venous insufficiency (CVI). MethodsThe medical records of patients who had undergone EVLA, NBCA, or RFA for CVI from January 1, 2014 to January 1, 2017 were reviewed. The medical records included data on sex, age, body mass index, American Society of Anesthesiologists score, and symptoms at admission. The great saphenous vein diameter, CEAP (Clinical, Etiology, Anatomy, and Pathophysiology) classification, and venous clinical severity score were also recorded. All the patients were followed up with physical examinations and color Doppler ultrasound scan at the first week and 6 and 12 months after treatment. After 12 months, the follow-up examinations were performed annually. ResultsA total of 232 patients who had undergone lower limb CVI surgical treatment (EVLA, n = 77; NBCA, n = 73; RFA, n = 82). The mean follow-up time was 67.5 ± 4.7 months. The procedure duration was significantly shorter for the NBCA group (13.5 minutes) vs that for the EVLA (31.7 minutes) and RFA (27.9 minutes) groups (P = .001). The pain score was highest in the EVLA group (P = .001). The EVLA group had also experienced a significantly greater incidence of complications and a longer time to return to daily activities (P = .001). The post hoc analysis revealed comparable occlusion success among the three groups on the first postoperative day and at 6, 12, and 24 months postoperatively. However, significantly better occlusion rates were found for RFA vs EVLA at 3 and 5 years of follow-up (P = .024 and P = .011, respectively). The success of NBCA and RFA was similar at 3 and 5 years of follow-up (P = .123 and P = .330, respectively). ConclusionsThe outcomes showed similar early postoperative occlusion success among all three CVI treatment techniques. However, RFA resulted in a significantly higher success rate compared with EVLA at 3 and 5 years of follow-up. Additionally, the NBCA and RFA procedures achieved comparable long-term success. However, EVLA was associated with significantly greater complication rates and pain scores and a longer time to return to daily activities. The NBCA procedure had a significantly shorter operation time compared with the other procedures.

Electronically monitored occlusion therapy in amblyopia with eccentric fixation

PurposeAmblyopia with eccentric fixation, especially when not diagnosed early, is a therapeutic challenge, as visual outcome is known to be poorer than in amblyopia with central fixation. Consequently, treatment after late diagnosis is often denied. Electronic monitoring of occlusion provides us the chance to gain first focussed insight into age-dependent dose response and treatment efficiency, as well as the shift of fixation in this rare group of paediatric patients.MethodsIn our prospective pilot study, we examined amblyopes with eccentric fixation during 12 months of occlusion treatment. We evaluated their visual acuity, recorded patching duration using a TheraMon®-microsensor, and determined their fixation with a direct ophthalmoscope. Dose-response relationship and treatment efficiency were calculated.ResultsThe study included 12 participants with strabismic and combined amblyopia aged 2.9–12.4 years (mean 6.5). Median prescription of occlusion was 7.7 h/day (range 6.6–9.9) and median daily received occlusion was 5.2 h/day (range 0.7–9.7). At study end, median acuity gain was 0.6 log units (range 0–1.6) and residual interocular visual acuity difference (IOVAD) 0.3 log units (range 0–1.8). There was neither significant acuity gain nor reduction in IOVAD after the 6th month of treatment. Children younger than 4 years showed best response with lowest residual IOVAD at study end. Efficiency calculation showed an acuity gain of approximately one line from 100 h of patching in the first 2 months and half a line after 6 months. There was a significant decline of treatment efficiency with age (p = 0.01). Foveolar fixation was achieved after median 3 months (range 1–6). Three patients (> 6 years) did not gain central fixation.ConclusionEccentric fixation is a challenge to therapy success. Based on electronic monitoring, our study quantified for the first time the reduction of treatment efficiency with increasing age in amblyopes with eccentric fixation. Despite some improvement in patients up to 8 years, older patients showed significantly lower treatment efficiency. In younger patients with good adherence, despite poor initial acuity, central fixation and low residual IOVAD could be attained after median 3 months. Hence, the necessity of early diagnosis and intensive occlusion should be emphasized.

First Experience of Three Neurovascular Centers With the p64MW-HPC, a Low-Profile Flow Diverter Designed for Proximal Cerebral Vessels With Antithrombotic Coating.

Background: In the last decade, flow diversion (FD) has been established as hemodynamic treatment for cerebral aneurysms arising from proximal and distal cerebral arteries. However, two significant limitations remain—the need for 0.027” microcatheters required for delivery of most flow diverting stents (FDS), and long-term dual anti-platelet therapy (DAPT) in order to prevent FDS-associated thromboembolism, at the cost of increasing the risk for hemorrhage. This study reports the experience of three neurovascular centers with the p64MW-HPC, a FDS with anti-thrombotic coating that is implantable via a 0.021” microcatheter.Materials and methods: Three neurovascular centers contributed to this retrospective analysis of patients that had been treated with the p64MW-HPC between March 2020 and March 2021. Clinical data, aneurysm characteristics, and follow-up results, including procedural and post-procedural complications, were recorded. The hemodynamic effect was assessed using the O'Kelly–Marotta Scale (OKM).Results: Thirty-two patients (22 female, mean age 57.1 years) with 33 aneurysms (27 anterior circulation and six posterior circulation) were successfully treated with the p64MW-HPC. In 30/32 patients (93.75%), aneurysmal perfusion was significantly reduced immediately post implantation. Follow-up imaging was available for 23 aneurysms. Delayed aneurysm perfusion (OKM A3: 8.7%), reduction in aneurysm size (OKM B1-3: 26.1%), or sufficient separation from the parent vessel (OKM C1-3 and D1: 65.2%) was demonstrated at the last available follow-up after a mean of 5.9 months. In two cases, device thrombosis after early discontinuation of DAPT occurred. One delayed rupture caused a caroticocavernous fistula. The complications were treated sufficiently and all patients recovered without permanent significant morbidity.Conclusion: Treatment with the p64MW-HPC is safe and feasible and achieves good early aneurysm occlusion rates in the proximal intracranial circulation, which are comparable to those of well-established FDS. Sudden interruption of DAPT in the early post-interventional phase can cause in-stent thrombosis despite the HPC surface modification. Deliverability via the 0.021” microcatheter facilitates treatment in challenging vascular anatomies.

Impacts of Transcranial Direct Current Stimulation on the Action Observation Network and Sports Anticipation Task.

Effective anticipation skills in sporting cognition have been shown to facilitate expertise in sports. Transcranial direct current stimulation (tDCS) has shown to improve motor and cognitive functioning. Therefore, this study aimed to determine the assistive effects of tDCS on the action observer network in both novice and expert gamers during an occlusion task, as well as the related electroencephalographic spectral power response. Twenty-three novice and 23 expert video gamers received either sham or active tDCS with a right parietal anode and left frontal cathode. Only experts demonstrated a significant improvement in predicting ball direction for the overall and early occlusions after tDCS. Spectral power results revealed significant changes in theta, high-gamma, and delta frequencies. The findings indicate that tDCS was able to modulate anticipatory behavior and cortical activity in experts compared with novice participants, suggesting a facilitatory role for tDCS to improve anticipatory effects and assist as a neurocognitive training technique.

Fluoroscopy-guided percutaneous antegrade approach for ureteral stent placement in children: a single-center experience.

Although there are many studies on percutaneous nephrostomy in urinary obstruction management in pediatric patients, there is a limited number of studies on percutaneous antegrade ureteral stenting (PAUS) on this issue. To evaluate the results of fluoroscopy-guided percutaneous antegrade approach for ureteral stent placement through the nephrostomy route in children. Between October 2005 and June 2019, the medical records of children who underwent PAUS through the nephrostomy route were reviewed retrospectively. Demographic data of the patients, technical and clinical success rates, technical details, and complications of the procedure were recorded. Patients were divided and evaluated into groups according to etiology. Categorical data were analyzed by using the Pearson chi-square test. In total, 31 patients (19 boys, 12 girls; age range = 2 months-18 years; mean age = 7.4 ± 6.01 years) and 42 procedures were included in the study. The most common underlying diseases were ureteropelvic junction obstruction (16 stents, 38.1%) and vesicoureteral reflux (13 stents, 31%). The technical and clinical success rates were 97.6% and 90%, respectively. Clinical failure (10%) was not related to gender, underlying diseases, and stent size (P > 0.05). Mean stent dwelling time was 96.43 ± 58.1 days. Complications were urinary tract infection (two procedures), stent migration (two procedures), early occlusion (one procedure), and contrast material leak after balloon dilation (one procedure). The complication rate was 14.6%. No procedure-related death was observed. PAUS through the nephrostomy route in children is an effective and reliable method when surgical treatment is not feasible.

Early vessel occlusion and recanalization after photodynamic therapy in central serous chorioretinopathy by OCT angiography.

Early vessel occlusion and recanalization after photodynamic therapy in central serous chorioretinopathy by OCT angiography.

Thermal injury induces early blood vessel occlusion in a porcine model of brass comb burn

Burn wound progression is an important determinant of patient morbidity and mortality after injury. In this study, we used the brass comb contact burn to determine burn wound vertical injury progression with a focus on blood vessel occlusion and endothelial cell death. Class A 3-month-old Yorkshire pigs received a brass comb contact burn. Burn wounds were sampled at 0, 30 min, 1, 2, 4, and 24 h. Hematoxylin Phloxin Saffron staining and vimentin immunostaining were performed to determine the depth of blood vessel occlusion and endothelial cell death, respectively. The depth of blood vessel occlusion increased by 30 min (p < 0.005) and peaked by 1 to 4 h (p > 0.05). The depth of endothelial cell death risen to a plateau at 30 min (p < 0.005) to 2 h and then peaked at 24 h (p < 0.03). We observed a progression of blood vessel occlusion and vascular endothelial cell death from the middle of the dermis to the hypodermis within 2 h to 4 h after the initial injury, namely a progression from a second-degree (partial thickness) to third-degree (full thickness) burn. These data suggest that therapeutic interventions during this time window may provide a better outcome by reducing or preventing vertical progression of blood vascular occlusion or endothelial cell death.

Woven EndoBridge (WEB) Width at the Aneurysm Neck Level Affects Early Angiographic Aneurysm Occlusion

PurposeEndovascular therapy with the Woven EndoBridge (WEB) device is a safe treatment approach, whereby neoendothelialization at the neck area is a crucial element for aneurysm occlusion. We hypothesized that WEB sizing at the aneurysmal neck level has an impact on early aneurysm occlusion.MethodsPatients with short-term follow-up digital subtraction angiography following WEB treatment of unruptured aneurysms were included. Aneurysms were categorized according to the Bicêtre Occlusion Scale Score (BOSS) as adequately (BOSS 0, 0′, 1) or partially occluded (BOSS 2, 3, 1 + 3). The WEB device dimensions, including the average aneurysm diameter (AADi) and the average neck diameter (ANDi) as well as baseline patient characteristics were documented.ResultsIn this study 75 patients with 76 aneurysms were included and 65 aneurysms showed adequate occlusion at short-term follow-up (86%). In univariable logistic regression analysis, smaller differences in WEB size to ANDi (D-ANDi) were significantly associated with adequate aneurysm occlusion (odds ratio, OR = 0.41, 95% confidence interval, CI 0.23–0.71, p = 0.002). Receiver operating characteristic (ROC) curve analyses displayed higher discriminative power for the D‑ANDi (AUC = 0.77, 95% CI 0.66–0.86, cut-off ≤2.9 mm) compared to the difference in WEB size to the average aneurysm diameter (D-AADi, AUC = 0.65, 95% CI 0.53–0.75, cut-off ≤1.0 mm).ConclusionSmaller differences between the WEB width and ANDi were associated with adequate early aneurysm occlusion and might thus have a higher impact on the results than the traditional device sizing considering the mean aneurysm diameter. D‑ANDi ≤2.9 mm served as an optimal cut-off to classify occlusion after WEB treatment at the short-term follow-up. Further external validation is warranted.

Novel Uses of Lumen-apposing Metal Stents: A Review of the Literature.

The field of therapeutic endoscopy has seen many recent advancements. One such emerging field is the use of lumen-apposing metal stents (LAMS). Although a few LAMS have been developed, the most commonly reviewed and the only Food and Drug Administration (FDA)-approved LAMS is the Axios stent by Boston Scientific. In 2013, LAMS were initially approved by the FDA for the management of pancreatic fluid collection drainage in the presence walled-off necrosis. Pancreatic fluid collections are traditionally drained with either a plastic stent or a covered biliary self-expanding metal stent. Plastic stents have a double pigtail feature which prevents stent migration. However, their narrow lumen poses limitations as it can lead to early stent occlusion. Fully covered metal stents have larger diameters, allowing improved drainage and decreased stent occlusion but their tubular shape is prone to migration. Consequently, this results in leakage, and frequent retrievals. Over the years, due to their versatility, LAMS now have many off label uses. This includes management of gastric outlet obstruction, superior mesenteric artery syndrome, strictures, gallbladder drainage, and postsurgical collection drainage. In this review, we will be discussing the FDA approved and the nonapproved uses of LAMS.

CSF shunt valve occlusion-does CSF protein and cell count matter?

Shunt obstruction is a common cause of shunt failure in the treatment of hydrocephalus. Valve occlusion is traditionally believed to originate from elevated CSF protein or cellular components, although detailed evidence is scarce and contradictory. Therefore, this study aimed to examine CSF protein and cell count as risk factors for valve obstruction. We retrospectively examined 274 patients who underwent shunt placement for hydrocephalus between 2009 and 2018 and had at least 1year follow-up. Age, aetiology of hydrocephalus, valve type, occurrence of revision, reason for revision and CSF protein and cell count at the time of shunt insertion and revision surgery were analysed. Thirty-two of 274 patients (11.7%) required revision surgery due to valve occlusion. Mean time to revision was 143days. CSF white blood cell (WBC) count but not protein was associated with valve occlusion overall. Of all obstructed valve patients, 25% showed CSF protein level within the normal range, whereas 13.6% of the patients overall showed greatly elevated CSF protein level without evidence of valve obstruction. Persistently elevated CSF protein level at the time of shunt revision was significantly associated with valve obstruction within 90days of initial insertion (early occlusion). Children with congenital malformations and post-haemorrhagic patients were significantly overrepresented in the occlusion group, particularly in the early occlusion group. Pathological CSF values such as WBC count and persistently elevated protein level serves as a risk factor for early valve obstruction. Late obstruction occurs independent of normal CSF values. Infants are particularly prone to early and late valve obstructions. CSF protein level at shunt insertion is not predictive of valve occlusion.

Xenogeneic materials for the surgical treatment of aortic infections.

BackgroundThe surgical treatment of aortic infections (AIs) is challenging. In situ aortic reconstructions represent nowadays the favored therapy for fit patients and xenogeneic materials are used increasingly. The aim of this study was to present our experience with xenogeneic reconstructions for AI using self-made bovine pericardium tubes and/or the biosynthetic Omniflow® II graft.MethodsThis retrospective single-center study included all patients undergoing xenogeneic aortic and aortoiliac reconstructions from December 2015 to June 2020. Patient comorbidities, symptoms, procedural characteristics, types of pathogens and postoperative outcomes were analyzed.ResultsTwenty-eight patients [23 male (82%), median age 68 (range, 28–84) years] were included. Ten patients (36%) had native AIs and 18 (64%) had graft infections, including 3 (11%) aortoesophageal and 2 (7%) aortoduodenal fistulas (ADF). Twenty-four patients (86%) were symptomatic, the most common symptoms being contained aortic rupture (n=8) and sepsis (n=4). The surgical procedures were infra- and juxtarenal aortic repairs (n=11, 39% and n=7, 25%), thoracoabdominal aortic repairs (type IV: n=1, 4%; type V: n=3, 11%), descending thoracic aortic repairs (n=4, 14%) and 2 reconstructions (7%) involving the ascending aorta/aortic arch. Most were urgent (n=10, 43%) or emergent operations (n=11, 35%). Identification of pathogen(s), mostly Gram-positive bacteria, was possible in 25 patients (89%). Twelve patients (43%) had polymicrobial infections and 6 (21%) infections with multi-resistant bacteria. In-hospital mortality was 32% (n=9) due to acute cardiac failure (1/9), endocarditis (1/9), bleeding (3/9) and sepsis (4/9). The most frequent complications were transient need for dialysis (n=12, 43%) and persisting sepsis (n=11, 39%). Two early occlusions of Omniflow® II grafts were observed (7%). Median follow-up (FU), during which 2 patients died of non-aortic causes, was 14 months (95% CI: 9–19 months). Freedom from reoperation was 100%, there was no evidence for reinfection during FU.ConclusionsXenogeneic orthotopic reconstructions for AI can be performed at all aortic levels. Combining bovine pericardium and the Omniflow® II graft can be useful for reconstructing the branched aortic segments and both materials show appropriate early to midterm outcomes. Nonetheless, AIs are serious conditions associated with relevant morbidity/mortality rates, even in a specialized center.

Early radial artery occlusion following the use of a transradial 7-French sheath for complex coronary interventions in Chinese patients.

We aimed to explore the impact of 7-Fr sheaths on the incidence of early radial artery occlusion (RAO) after transradial coronary intervention (TRI) in Chinese patients. RAO precludes future use of the vessel for vascular access. Transradial catheterization is usually performed via 5-Fr or 6-Fr catheters; 7-Fr sheath insertion enables complex coronary interventions but may increase the RAO risk. We prospectively enrolled 130 consecutive patients undergoing complex TRI using 7-Fr sheaths. Radial artery ultrasound assessment was performed before and after TRI. Early RAO was defined as the absence of flow on ultrasound within 6-24 hr after TRI. Multivariate logistic regression was used to determine the factors related to early RAO after TRI. 7-Fr sheaths were mainly used for chronic total occlusion (44.6%), bifurcation (30.0%), and tortuous calcification (25.4%) lesions. All patients were successfully sheathed. Percutaneous coronary intervention (PCI) procedural success was 96.2%; 119 patients (91.5%) had preserved radial artery patency after TRI. All 11 RAO cases (8.5%) were asymptomatic. The radial artery diameter was significantly larger postoperatively (3.1 ± 0.4 mm) than preoperatively (2.6 ± 0.5 mm) (p < .001). No parameters significantly differed between patients with and without RAO. TRI history was the only independent risk factor of early RAO (odds ratio: 6.047, 95% confidence interval: 1.100-33.253, p = .039). 7-Fr sheath use after transradial access for complex PCI is feasible and safe. Evaluating the radial artery within 24 hr after TRI allows timely RAO recognition, important for taking measures to maintain radial artery patency and preserve access for future TRIs.

Short-term outcomes of reconstruction of extensively diseased left anterior descending artery with or without endarterectomy: a propensity score analysis

BackgroundSurgical management of extensively diseased left anterior descending artery (LAD) is challenging. Reconstruction of the LAD with endarterectomy may lead to intimal disruption and affect the outcomes of surgery. We aimed to compare hospital outcomes of surgical reconstruction of extensively diseased LAD with and without endarterectomy.ResultsThis retrospective multicenter study included 275 patients who had reconstruction of extensively diseased LAD from 2015 to 2019. We divided patients into two groups: group 1 (n = 138) included patients who had plaque exclusion and patching, and group 2 (n = 137) included patients who had endarterectomy and patching. All patients had primary isolated on-pump coronary artery bypass grafting with the left internal mammary artery (LIMA) grafting to LAD. On-lay LIMA patch was used in 118 patients in group 1 and 132 patients in group 2. A saphenous vein patch was used in 20 patients in group 1 and 5 patients in group 2. Propensity score matching identified 100 matched pairs. The age in group 1 was 56.1 ± 7.8 years versus 55.2 ± 7.1 in group 2 (P = 0.34). There were 119 (86.2%) males in group 1 and 113 (82.5%) in group 2 (P = 0.39). After matching, there was no difference in preoperative and operative data. In the matched groups, low cardiac output occurred in 6 (6%) patients in group 1 and 4 (4%) patients in group 2 (P = 0.73). There was no difference in mechanical ventilation time between groups (9 (25th- 75th percentiles: 7.5–14) hours in group 1 vs. 9 (7–14) hours in groups 2; P = 0.93). Length of hospital stay was 7 (6–9) days in group 1 and 7 (6–10) days in group 2 (P = 0.57). Mortality occurred in one patient in group 1. We did not report early graft occlusion cases in group 1, and one patient had a myocardial infarction in group 2.ConclusionThe outcomes after reconstructing extensively diseased LAD with endarterectomy or plaque exclusion and patching are satisfactory and comparable in both approaches.

Patches of different types for carotid patch angioplasty.

Patches of different types for carotid patch angioplasty.

Widening the Indications for Intrasaccular Flow Disruption: WEB 17 in the Treatment of Aneurysm Locations Different from Those in the Good Clinical Practice Trials.

The safety and efficacy of the Woven EndoBridge (WEB) device has been shown in multiple good clinical practice trials, whereas aneurysm locations in these trials were restricted to bifurcation aneurysms located at the circle of Willis (MCA bifurcation, ICA bifurcation, anterior communicating artery, basilar artery tip). Our aim was to evaluate angiographic and clinical results with the WEB 17 in aneurysm locations that were excluded from the good clinical practice trials, assuming that the angiographic and clinical results are similar to those of the good clinical practice trials for aneurysms in traditional locations. We performed retrospective analysis of immediate and follow-up results of aneurysms in locations outside the good clinical practice trials in which the WEB 17 was used on an intention-to-treat approach. Between June 2017 and May 2020, forty-seven aneurysms in 44 patients met the inclusion criteria. Aneurysm locations were the ICA posterior communicating artery in 19 (40.3%), the ICA paraophthalmic or choroidal locations in 4 (8.6%), anterior cerebral artery A2 segment in 13 (27.7%), MCA M1 segment in 2 (4.3%), posterior cerebral artery P2 segment in 2 (4.3%), PICA in 3 (6.4%), and the superior cerebellar artery in 4 (8.4%) cases. The procedure-related morbidity and mortality rates in the entire series were 0.0%. The early and late (<12 and >12 months) complete occlusion rates were 63.9% (23/36) and 77.8% (14/18), respectively. The WEB 17 is safe and effective in aneurysm locations different from the traditional bifurcation aneurysms included in the good clinical practice trials. Further studies will help to define the entire spectrum of aneurysm morphologies and locations suitable for the WEB 17.

COMPARISON OF INTRAVENOUS VERSUS INTR-ARTERIAL HEPARIN FOR THE PREVENTION OF RADIAL ARTERY OCCLUSION DURING TRANSRADIAL CORONARY ARTERY CATHETHERIZATION

Objective: To determine the relative efficacy of intravenous heparin as compared to intra-arterial heparin used during transradial coronary angiography for the prevention of radial artery occlusion.&#x0D; Study Design: Comparative cross-sectional study.&#x0D; Place and Duration of Study: Study was conducted at the Department of Cardiology, AFIC/NIHD Rawalpindi, Pakistan, from Jul 2019 to Dec 2019.&#x0D; Methodology: A total number of 144 patients were considered for the study using the consecutive sampling technique who were undergoing diagnostic coronary angiography. Patients were divided into the intra-arterial group (n=72) who received 50 IU/kg of unfractionated heparin (maximal dose 5,000 U) intra-arterially, and an intravenous group (n=72) received the similar dose through intravenous route. All patients were administered 100 mcg of nitroglycerin to minimize radial artery spasm. Coronary Angiography was performedusing a 6F introducer sheath and diagnostic catheters. Early radial artery occlusion (RAO) at 24 hours after the procedure was detected by performing the plethysmographic (reverse Barbeau’s) and doppler USG evaluation. Chronic RAO was assessed 30 days after the procedure by performing the same tests. Data was collected through a predesigned proforma and analyzed using SPSS 23. A p-value of less than 0.05 was considered as significant.&#x0D; Results: Early RAO was found in 4 (5.6%) of the patients from the intra-arterial groupand 5 (6.9%) of the intravenous group. The difference was found to be statistically insignificant (p-value 0.731). Chronic RAO was observed in 3 (4.4%) of the intra-arterial group as compared to 4 (6%) of the intravenous group. This difference was also statistically insignificant (p-value 0.683) for chronic RAO.&#x0D; Conclusion: Intra-arterial and intravenous heparin administration providedsimilar efficacy to prevent RAO.

Complete or Partial Parent Artery Sacrifice: Effect of Vessel-Occlusion Strategies on Complete Obliteration of Complex Aneurysms

A small number of complex intracranial aneurysms are not amenable to direct clipping strategies or endovascular treatment. In these patients, parent artery sacrifice and bypass revascularization for aneurysm occlusion is an option. There are 3 strategies for parent artery sacrifice: trapping, complete occlusion of the inflow, and outflow segment; proximal occlusion of the inflow vessel; and distal occlusion of the outflow vessel(s). This study aimed to compare these techniques with regard to aneurysm occlusion rates. We reviewed our database for cerebral revascularization before parent artery sacrifice to treat cerebral aneurysms. We assessed aneurysm occlusion rates 3 and 12 months after surgery, outcome, and postoperative aneurysm rupture. In total, 121 patients underwent parent artery sacrifice for complex aneurysms; 30% of the parent arteries were trapped, 58% proximally, and 12% distally occluded. Postoperative digital subtraction angiography revealed an aneurysm occlusion rate of 100% after trapping. Proximal occlusion led to early complete aneurysm occlusion in 71% of the cases, 21% occluded during follow-up. The complete occlusion rate was 96%, distal occlusion had an early aneurysm occlusion rate of 40%, 40% occluded during follow-up. Complete aneurysm occlusion rate was only 80%. All 3 techniques resulted in a volume reduction of more than 60% without a significant difference between the groups. The annual aneurysm rupture rate after distal parent artery sacrifice was 15%; there was no rupture after trapping or proximal parent artery sacrifice. Trapping and proximal parent artery sacrifice seem to be superior to distal parent artery sacrifice regarding occlusion and rupture rates.

Hybrid Approach to Popliteal Artery Aneurysm with Thromboembolic Symptoms. A Pilot Study

The treatment of patients with thromboembolic symptoms due to a popliteal artery aneurysm (PAA) is still controversial with poor results in terms of primary patency. The aim of our pilot study was to evaluate whether improving the outflow with an endovascular pretreatment consisting in thromboaspiration and angioplasty could positively ameliorate the primary patency of the subsequent femoropopliteal (FP) bypass in symptomatic patients with at least one below the knee (BTK) patent vessel. This is a single-center pilot case-control study that involves patients treated at the Vascular and Endovascular Surgery Unit of Udine, Italy, from January 2015 to November 2019. The inclusion criteria were the presence of thromboembolic symptoms due to PAA distal embolization, associated with the presence of a patent PAA >20mm and a poor runoff (no more than one patent BTK artery). The case group was treated in a two-step approach: the first step consisted in thromboaspiration followed by BTK angioplasty, when appropriate, and the second one consisted in performing the surgical FP bypass. The control group moved on directly to the open surgical intervention. The case group was composed of 11 patients, 10 males and 1 female, with a mean age of 69.3±10.8years. The mean PAA dimension was 32.6±9.9mm. Particularly, 9 patients were operated on through the medial vascular approach and 2 through the posterior one. The grafts used were 10 polytetrafluoroethylene (PTFE) and 1 great saphenous vein (GSV) in situ. The control group was composed of 11 male patients with a mean age of 75.5±8.7years, and the mean PAA dimension was 29.8±13.4mm. All the FP bypasses were approached medially, and the materials used were 10 PTFE and 1 reversed GSV. The median follow-up was 31.5±12.6months. Primary patency in the case group was 72.7% within one year; on the contrary, it was 27.3% in the control group. The amputation rate was 0% in the case group, 27.3% in the controls. By comparing the 2 groups, we found a higher and significant risk (P=0.0261) of early FP bypass occlusion and major limb amputation in the control group. This pilot study shows encouraging results; the endovascular approach is a safe and repeatable procedure which, improving the runoff in thromboembolic symptomatic PAA, seems to guarantee a better FP graft primary patency.

Late Free Flap Failure in Head and Neck Reconstruction: Unusual Etiology in Two Case Studies and Literature Review.

The development of modern microvascular surgical techniques has enabled the reliable transfer of free vascularized tissue. This allowed for predictable reconstruction outcomes with excellent surgical success rates. However, devastating consequences of partial or total flap failure and subsequent loss may occur. This usually occurs in the first 48-72h post-operatively. It is rare for flaps to fail in the late post-operative period and it remains poorly understood why flaps fail after day seven. We presented two patients in whom flap failure occurred after the seventh post-operative day (POD). Complete flap failure occurred after POD 9 and 27 in our cases. During the postoperative period, there was no evidence of early occlusion or insult to the vascular integrity such as venous/arterial compression. The cause of late flap failure was due to thrombophlebitis secondary to infection from the tracheostomy-neck fistula. This assumption was supported by recurrent failure of anastomoses revision.

Stent characteristics of 32 patients with early (

ObjectiveEndovascular treatment with percutaneous transluminal angioplasty and stenting has quickly gained popularity for treatment of deep venous obstructive disease. Early thrombosis after stenting in iliofemoral veins is uncommon. The treatment and analysis of the underlying factors leading to the rethrombosis of stents placed in the previous 14 days are reported in this study. MethodsPatients diagnosed with early in-stent thrombosis after iliofemoral stenting were reviewed in this retrospective analysis. Patients with acute occlusion were routinely treated by catheter-directed thrombolysis (CDT), and the underlying causes of early occlusion were identified during the procedure. After successful CDT procedures, patients received additional interventions (percutaneous transluminal angioplasty with or without stenting) if indicated. ResultsA total of 527 patients underwent stenting in the iliofemoral veins, and 32 patients (20 men [63%]) with acute thrombosis in iliofemoral venous stents placed in the previous 14 days were treated in our center from January 2015 to December 2018. The mean time from the onset of symptoms to the intervention was 6 days. Successful thrombolysis was achieved in 31 of the 32 patients, and additional stents were implanted in 16 patients. Patency was achieved in all cases. The underlying factors of early stent thrombosis were technical failure of the initial procedure, such as suboptimal positioning, failure owing to stent characteristics (stent kinking, compression, and angulation), in-stent residual thrombus, and inadequate anticoagulation. In all cases, recanalization was achieved through successful thrombolysis with or without restenting. ConclusionsTreatment with CDT and stenting of early in-stent thrombosis is effective and feasible. Recanalization of stented segment(s) can be achieved in most cases of recent thrombosis (<14 days). Early stent-related occlusion is mainly caused by stent-related problems and technical inadequacies.