Endovascular Surgeons Research Articles

The Untold Story: Early and Mid-Term Results of Subintimal Angioplasty in Superficial Femoral Artery Versus Popliteal Artery Chronic Total Occlusion.

This study aims to compare the immediate and mid-term outcomes of subintimal angioplasty (SIA) of chronic total occlusions (CTOs) of superficial femoral artery (SFA) versus popliteal artery (PA) and to identify possible predictors of loss of limb-based patency (LBP). This is a retrospective analysis of chronic lower-limb ischemia (CLI) patients (Rutherford classes 3-6) presenting with CTO of SFA or PA treated by SIA and selective stenting in the period 2018 to 2021. Immediate outcomes were compared between the SFA and PA groups, including technical success, perioperative complications, and 30-day major amputation and mortality rates. Mid-term outcomes for technically successful procedures included limb-based patency (LBP), wound healing rate, amputation-free survival (AFS), and major adverse limb events (MALEs). A total of 450 CLI patients underwent SIA of CTO at the SFA (n=260, 57.8%) and the PA (n=190, 42.2%). The indication for revascularization was chronic limb-threatening ischemia in 80.8% of SFA group and 84.2% of PA group. Technical success rate was higher in the PA group compared to the SFA group (96.3% vs 91.2%; p=0.03). The 30-day amputation rates were comparable between the SFA and PA groups (7.7% vs 6.8%, p=0.7, respectively). No perioperative mortality or systemic major complications occurred in the present study. Kaplan-Meier estimate of the 1-year rates were significantly better for SFA group regarding LBP (82% for SFA group vs 43% for PA group, p=0.006), AFS (88% vs 64%, p=0.02), and wound healing (79% vs 58%, p=0.027), respectively. The number of runoff vessels was the only factor associated with loss of LBP (hazard ratio [HR], 0.055; 95% confidence interval [CI]: 0.001-3.020, p=0.039). Subintimal angioplasty is an effective and safe endovascular treatment option of CTO at SFA and PA with satisfactory immediate outcomes. The mid-term outcomes, however, are better for SFA lesions in terms of improved LBP, AFS, and wound healing rates. Subintimal angioplasty is a valuable tool in the armamentarium of endovascular surgeons, as re-entry devices aren't always widely accessible. This study aims to assess the technical outcomes of peripheral vascular interventions for infrainguinal chronic total occlusions and identify possible predictors for successful subintimal angioplasty .Subintimal angioplasty is an effective treatment option for infrainguinal CTO with difference in result of immediate outcomes in popliteal lesions and SFA lesions.

Bypass versus Angioplasty in Severe Ischaemia of the Leg (BASIL)-2 Trial: Analysis of the Timing and Causes of Death in Participants Randomised to an Infrapopliteal Vein Bypass or Best Endovascular Treatment First Revascularisation Strategy

The Bypass versus Angioplasty in Severe Ischaemia of the Leg (BASIL)-2 trial enrolled participants with chronic limb threatening ischaemia who required an infrapopliteal, with or without a femoropopliteal, revascularisation procedure to restore limb perfusion. Participants randomised to a vein bypass (VB) first revascularisation strategy were over one third more likely than those randomised to a best endovascular treatment (BET) first revascularisation strategy to die from any cause during a median follow up of 40.0 (interquartile range 20.9, 60.6) months. The aim of the present study was to describe the timing and causes of death in BASIL-2 as a first step towards trying to better understand why randomisation to a VB first revascularisation strategy was associated with this excess mortality. A 10 person international panel comprising vascular and endovascular surgeons as well as vascular interventional radiologists, who had all been principal investigators in BASIL-2, took part in a modified Delphi consensus exercise to adjudicate the primary cause of death and, in particular, whether the cause was primarily cardiac or non-cardiac. In 151 of 168 deaths (89.9%), the Delphi panel achieved a consensus regarding the cause of death being probably cardiac or non-cardiac. In the BET group, 16 of 77 deaths (21%) were classified as probably cardiac compared with 32 of 91 (35%) in the VB group (unadjusted subdistribution hazard ratio 2.16, 95% confidence interval [CI] 1.20 - 3.87; unadjusted cause specific hazard ratio 2.15, 95% CI 1.19 - 3.90). At the point of randomisation, 64 of 344 (18.6%), 40 of 342 (11.7%), and 37 of 344 (10.8%) participants had a previous myocardial infarction (MI), percutaneous coronary intervention (PCI), and coronary artery bypass graft (CABG), respectively. There was no evidence of varying treatment effects for cause of death in subgroup analyses of previous PCI, CABG, or MI. The excess mortality observed in the VB first revascularisation strategy group in BASIL-2 was largely due to deaths that were adjudicated by the Delphi panel as probably primarily cardiac. These excess cardiac deaths were observed throughout follow up and there was no evidence of non-proportional hazards. Further work is ongoing to try to better understand the reasons for these findings.

Prevalence of Risk Factors in Patients with Postprocedural Ischemic Lesions after Coiling of Very Small Intracranial Aneurysms.

Background: Very small intracranial aneurysms, generally considered to be those 3 mm in diameter or smaller, pose particular technical challenges for endovascular surgeons. For this reason, very small aneurysms have been excluded from many relevant studies. The aim of our research was to establish the risk factors for the occurrence of stroke complications after endovascular embolization of ruptured and unruptured small intracranial aneurysms. Methods: During the period of 2009-2023, our team performed endovascular embolizations of intracranial aneurysms in 1567 patients across four different centers within the territory of Serbia and Montenegro. Within the total number of patients mentioned, aneurysms of less than 4 mm were treated 185 times, with 119 ruptured and 66 unruptured. Results: In the group of 119 patients with ruptured small intracranial aneurysms, 19 (16%) patients had ischemia after the endovascular treatment, 6 (5%) patients had minor neurological deficits, while 13 (10.9%) patients had major neurological deficits, of which 6 (5%) patients died. In the group of 66 patients with unruptured small intracranial aneurysms, 7 (10.6%) patients had ischemia after the endovascular treatment, 5 (7.6%) patients had minor neurological deficits, and 2 (3.03%) had major neurological deficits. Multivariate binary logistic regression showed that the risk factors for the occurrence of ischemia were the patient's age, smoking and alcohol consumption. The type of endovascular treatment used also had a statistically significant effect on the development of ischemia. Conclusions: Understanding the influence of possible risk factors for the occurrence of ischemic insult after embolization of small intracranial aneurysms is of great importance. By recognizing them, periprocedural complications can be reduced to a minimum.

Experts’ views on recurrence and progression of varicose veins

Introduction. Despite modern advances in technologies for the treatment and prevention of varicose veins, there is currently no radical treatment for varicose veins. The probability of recurrence of dilated veins, according to various authors, ranges from 5 to 70%. Along with the well-established concept of recurrence of varicose veins, the term progression of varicose veins is increasingly common in everyday life.Aim. To study the current understanding of the term relapse and the practical attitude of specialists involved in the treatment of varicose veins to it.Material and methods. In 2023, a survey of 117 specialists on the recurrence/progression of varicose veins was conducted. The respondents were doctors involved in the treatment of varicose veins: vascular surgeons 22.4%, phlebologists 50%, general surgeons 19.8%, specialists in ultrasound/functional diagnostics 7.8%, X-ray endovascular surgeon 0.85%. The questionnaire included 18 questions regarding the frequency of visits of patients with relapse/progression of varicose veins; views on tactics, as well as the attitude of specialists to the issue of progression and recurrence of varicose veins in patients after its surgical treatment.Results and discussion. The concept of recurrence and progression of varicose veins among specialists dealing with this pathology is not always comparable. There are differences in views both on the predisposing factors for the recurrence of dilated veins, and, accordingly, on the tactics of treatment and preventive measures. In some cases, according to statistics, they are due to specialization.Conclusions. The incidence of relapse and progression at the reception of the respondents has a slight difference. Despite the fact that there are opinions that do not correspond to generally accepted and abhorrent collegiality, mostly specialists try to separate these concepts, see differences in provoking factors and, accordingly, in recommendations.

Selection of optimal revascularization tactics in patients with polyvascular disease: a literature review

Patients with polyvascular disease (PVD), involving two or more vascular beds, are a difficult group for cardiologists, cardiovascular surgeons and endovascular surgeons. The relevance of the problem is due to its widespread prevalence, rapid progression, and comorbidity, which worsens the prognosis in this cohort of patients. The problem of selecting the optimal revascularization tactics remains unresolved. The results of original research on this problem are analyzed. The need for an individual multidisciplinary approach to determine the best revascularization strategy is demonstrated. The use of various methods of optimal therapy, open and endovascular surgery in each specific case is the most acceptable tactic.

Editor's Choice – Development and Testing of Step, Error, and Event Frameworks to Evaluate Technical Performance in Peripheral Endovascular Interventions

Tools for endovascular performance assessment are necessary in competency based education. This study aimed to develop and test a detailed analysis tool to assess steps, errors, and events in peripheral endovascular interventions (PVI). A modified Delphi consensus was used to identify steps, errors, and events in iliac-femoral-popliteal endovascular interventions. International experts in vascular surgery, interventional radiology, cardiology, and angiology were identified, based on their scientific track record. In an initial open ended survey round, experts volunteered a comprehensive list of steps, errors, and events. The items were then rated on a 5-point Likert scale until consensus was reached with a pre-defined threshold (Cronbach's alpha > 0.7) and > 70% expert agreement. An experienced endovascular surgeon applied the finalised frameworks on ten previously videorecorded elective PVI cases. The expert consensus panel was formed by 28 of 98 invited proceduralists, consisting of three angiologists, seven interventional radiologists, five cardiologists, and 13 vascular surgeons, with 29% from North America and 71% from Europe. The Delphi process was completed after three rounds (Cronbach's alpha; αsteps = 0.79; αerrors = 0.90; αevents = 0.90), with 15, 26, and 18 items included in the final step (73 - 100% agreement), error (73 - 100% agreement), and event (73 - 100% agreement) frameworks, respectively. The median rating time per case was 4.3 hours (IQR 3.2, 5 hours). A median of 55 steps (IQR 40, 67), 27 errors (IQR 21, 49), and two events (IQR 1, 6) were identified per case. An evaluation tool for the procedural steps, errors, and events in iliac-femoral-popliteal endovascular procedures was developed through a modified Delphi consensus and applied to recorded intra-operative data to identify hazardous steps, common errors, and events. Procedural mastery may be promoted by using the frameworks to provide endovascular proceduralists with detailed technical performance feedback.

Surgical Extraction of Residual CVC Guide Wire after One Year: Case Report

Complete remaining guide wire in the vascular system after CVC is very rare. For which the maximum symptom-free reporting time in studies was five months, and in our case, the patient was symptom-free for one year. The only finding was one session complaining of ear pain and mastoid tenderness two weeks after catheter placement.
 A 42-year-old male patient with the diagnosis of necrotizing pancreatitis and a retroperitoneal abscess was a candidate for laparotomy after ERCP. The patient was a candidate for central venous catheter insertion through the internal jugular vein before the surgery in the operating room by a third-year anesthesia resident. After one year, discovered that incidentally remaining guide wire during a follow-up MRI before pancreatitis. Which has been asymptomatic during this period. And despite the risk of rupture of the right heart and blood vessels due to possible fibrosis due to a long stay in the cardiovascular system, it is successfully removed by an endovascular surgeon.
 The main reasons for the incident were the non-observance of scientific and safety principles at the time of catheter insertion and the failure to perform CXR after that

Abstract WP79: Outcomes Of The Code Large Vessel Occlusion Process On Endovascular Intervention

Introduction: The code LVO alert was created to help decrease the time from arrival to MER for patients presenting with LVO stroke. The code LVO alerts the endovascular surgeon and team earlier in the stroke alert process with the goal of improving patient outcomes. The purpose of this study was to determine the impact of code LVO on stroke endovascular treatment times and patient outcomes. Methods: The code LVO is activated based on patient assessment. Criteria to call a code LVO includes a RACE score ≥ 5 or if a patient has disabling symptoms including aphasia, visual field cut or total limb weakness. The code LVO can be activated either as a prehospital alert or in the emergency department by either the provider or nurse. This notification makes the endovascular surgeon and team aware of a possible endovascular candidate prior to imaging to help reduce door to team activation, skin puncture, device, and reperfusion. We compared patients in 2022 that received MER with and without code LVO activation. Results: Eighteen patients with MER and code LVO activation were compared to 42 patients that received MER and no code LVO activation. Clinical and demographic characteristics were similar (p>.05). When comparing the two groups, the code LVO activation decreased the door to activation by 26.8 minutes (p=.003), door to puncture by 31.5 minutes (p=.005), door to device by 34.5 minutes (p=.026), and door to reperfusion by 41.3 minutes (p=.013). The 90-day mRS score and 90-day mortality rate were similar. Conclusion: In conclusion, the code LVO activation significantly decreased MER treatment times but these improvements did not translate to improved patient outcomes. We identified opportunities to improve our patient outcomes by increasing code LVO activation on all patients meeting criteria.

Possibilities of Therapeutic Angiogenesis in Patients with Critical Lower Limb Ischemia

Two clinical observations of effective treatment of patients with critical ischemia of the lower extremities using plasma-free lysate autologous platelets. Both patients were male, 73 and 53 years old. Both were diagnosed with total damage to the arteries of the infrainguinal zone. One of them had previously undergone endarterectomy from the femoral artery with subsequent thrombosis. After examination and joint discussion with x-ray endovascular surgeons, they were found inoperable. Due to the ineffectiveness of standard conservative therapy, the patient was offered local administration of plasma-free lysate autologous platelets. After receiving written informed consent, the procedure for collecting venous blood and obtaining plasma-free lysate autologous platelets and the introduction of this drug into the muscles of the leg from the side of ischemia according to the original method. The method for assessing microcirculation was three-phase scintigraphy : before treatment, both patients showed a significant decrease in the inclusion of osteotropic radiopharmaceutical in the soft tissues of the legs. For areas of radiopharmaceutical hyperfixation, relative accumulation coefficients were calculated: for one patient, the calculation results demonstrated the formation of foci of aseptic necrosis. When patients were re-hospitalized after 6 months, there was an improvement in local status and relief of rest pain. According to scintigraphy, a significant improvement in microcirculation was noted; no foci of aseptic necrosis were identified. Thus, the use of plasma-free lysate autologous platelets in combination with complex conservative therapy has demonstrated positive results; this method can be considered as an alternative revascularization ischemic limb.

СЕРИЯ КЛИНИЧЕСКИХ СЛУЧАЕВ ПРИМЕНЕНИЯ ЭКСТРАКОРПОРАЛЬНОЙ МЕМБРАННОЙ ОКСИГЕНАЦИИ ПРИ ВЫПОЛНЕНИИ ЧКВ ВЫСОКОГО РИСКА

Introduction. Percutaneous coronary interventions (PCI) have become increasingly intricate, particularly considering patient comorbidities. The simultaneous or staged coronary artery stenting in patients with ST-segment elevation myocardial infarction (STEMI) and multivessel coronary artery disease during the index hospitalization has garnered considerable interest. The utilization of venoarterial extracorporeal membrane oxygenation (VA-ECMO) in PCI has notably increased, serving both as an emergency intervention in acute myocardial infarction (AMI) and in planned PCI to maintain hemodynamics and organ perfusion. The term "high-risk PCI" has been introduced to denote interventions performed using short-term mechanical circulatory support, necessitating a multidisciplinary approach for patient management. Aim. This study aims to investigate the management approaches for high-risk PCI patients using mechanical circulatory support methods. Materials and Methods. A comprehensive literature review on the management of high-risk PCI patients was conducted. Patients with STEMI who underwent LCA trunk stenting at the bifurcation site using ECMO were selected based on the Barnaul ACCD. Results. Data on ECMO use in high-risk PCI are primarily limited to single-center observational studies or individual clinical cases. In the presented cases, ECMO facilitated successful implementation of complex PCI in patients with STEMI and critical stenoses of large coronary arteries. Indications for routine use of mechanical devices during PCI procedures should be individualized, considering potential benefits and complications. In the cases presented, ECMO use during XRD enabled complete revascularization despite acute heart failure and cardiogenic shock, leading to rapid patient stabilization and discharge in satisfactory condition. Conclusions. Managing high-risk PCI patients necessitates a multidisciplinary approach, requiring collaboration among endovascular surgeons, clinical cardiologists, and cardiac surgeons. Critical aspects in the intensive care unit for these patients are not yet fully understood, emphasizing the need to optimize patient condition pre-procedure, manage concurrent diseases, and ensure adequate postoperative care. The synergy between intensive care specialists and cardiologists can significantly impact treatment outcomes in this clinical context.

Systematic Review and Meta-analysis of Short-term and Mid-term Outcomes After Use of t-Branch Off-the-shelf Multibranched Endograft for Elective and Urgent Treatment of Thoracoabdominal Aortic Aneurysms.

To conduct a meta-analysis to assess the safety and efficacy of t-Branch off-the-shelf multibranched endograft for the treatment of thoracoabdominal aortic aneurysm (TAAA). PubMed, Embase, and Web of Science. Online databases were searched from June 2012 to March 2023. The data were pooled together using a random-effects model of proportions. The outcomes overall included technical success, spinal cord ischemia, target vessel occlusion, type I or III endoleak, reintervention, early mortality (30-day), and mid-term outcomes. Subgroup meta-analyses and meta-regression were performed to explore variation among studies. A total of 15 studies containing 1238 patients were included in the meta-analysis. The overall study quality assessment was found to be moderate to good. The pooled technical success was 97.0% (95% confidence interval [CI]=95.5-98.6, I2=53.01%, 1185/1238 cases, 15 studies). Overall, early mortality was 7.3% (95% CI=4.4-10.1, I2=74.48%, 124/1238 cases, 15 studies). Early spinal cord ischemia was 13.4% (95% CI=9.6-17.2, I2=67.24%, 160/1238 cases, 15 studies), and early type I or III endoleak was 6.0% (95% CI=3.4-8.5, I2=53.71%, 68/1032 cases, 9 studies). Mid-term outcomes showed target vessel occlusion was 4% (95% CI=1.4-6.5, I2=65.18%, 28/528 cases, 10 studies, 5-21.2 months), type I or III endoleak was 4.7% (95% CI=2-7.5, I2=49.74%, 38/512 cases, 10 studies, 5-21.2 months), reintervention was 11.2% (95% CI=8.1-14.3, I2=31.06%, 85/650 cases, 10 studies, 5-21.2 months), and pooled mortality was 13.9% (95% CI=7.2-20.7, I2=76.32%, 84/550 cases, 11 studies, 5-21.2 months). Meta-regression found a significant linear association between higher technical success and earlier publication year (p=0.014) and studies with anatomic inclusion criteria (p=0.037). Urgent patients (p=0.021) and later publication year (p=0.048) were significantly associated with higher early mortality. The use of the off-the-shelf t-Branch multibranched endograft for elective or urgent endovascular TAAA repair is associated with high technical success rates and proved to be safe and effective at early and mid-term follow-up. However, the heterogeneity between the included studies is high, and prospective, randomized studies along with future larger studies with long-term follow-up are needed. The Zenith t-Branch (Cook Medical, Bloomington, Ind) was approved as a commercially available device in Europe in June 2012. Although a decade has past, the outcomes of t-Branch have rarely been synthesized at the global level. This meta-analysis included 15 studies containing 1238 patients. The meta-analyses included technical success, major adverse events, reintervention, early mortality, and mid-term outcomes. The outcome was very meaningful and representative for the use of t-Branch. It is helpful for endovascular surgeons to make decisions on the treatment of TAAA patients.

THE PROBLEM OF TRANSCATHETER CLOSURE OF MULTIPLE ATRIAL SEPTAL DEFECTS: INTERVENTIONAL APPROACHES AND RESULTS. LITERATURE REVIEW

HighlightsThe article presents a review of the literature and the results of endovascular correction of multiple atrial septal defects, methods of occluder implantation. Indications for transcatheter closure and possible complications of the procedure are given. AbstractOver the past few decades, the treatment strategy for the second atrial septal defect has changed significantly. Due to the improvement of device technology and procedural techniques, transcatheter closure of atrial septal defects is currently considered to be the method of choice in most patients with secondary types of defects. The latest generation devices provide a simple and safe implantation. The use of biocompatible occluder materials contributes to endothelization and reduction of traumatization of nearby structures. Most of the currently available devices demonstrate excellent efficiency and comparable results with their own advantages and disadvantages. In addition to improving the properties and performance of the device, there was a clear improvement in the procedural technique because of numerous experiments with closing of the device. A difficult problem for an endovascular surgeon is the procedure for closing multiple defects, due to their shapes, locations on the septum, the lack of a sufficient amount of tissue edge on the septum, as well as difficulties with choosing the type of device, their number and relative location.

Surgical Treatment for Branched Endograft Thrombosis of the Abdominal Aorta

Introduction. Endovascular intervention was firstly introduced for repairing aortic aneurysms in the early 1990s. The greatest advantage of endovascular aneurysm repair (EVAR) is its minimally-invasive character, thus implying shorter post-operative period. The operative mortality rate comprises 3.3 % (95 % CI 2.9–3.6); however, according to recent studies, the rate has declined to 1.4 % due to a rapid improvement in outcomes. According to the DREAM-trial, the incidence of a branched endograft thrombosis accounts for 6.4% within the first 30 days. The EVAR trial reports an incidence of 2.6% after the first year of follow-up. Stent bending and small distal aortic diameters (less than 20 mm) are believed to be the most common causes of endograft thrombosis.Aim. To identify the causes of complications following the abdominal aortic stent-graft repair and to determine the optimal treatment strategy.Materials and methods. The paper presents a case of 71-year-old patient with late complication after endovascular abdominal aortic repair of an infrarenal aortic aneurysm. The patient was admitted to the hospital on January 05, 2020 as an emergency due to the pain in the left lower limb. On December 03, 2019 the patient underwent endovascular abdominal aortic repair. Angiography of January 06, 2020 revealed thrombosis of the left branch of the stent graft. Thrombectomy of the brunched left stent graft, left iliac artery and balloon dilatation of the brunched left stent-graft were performed.Results and discussion. Endovascular abdominal aortic repair stands as the first choice for patients with appropriate aortic anatomy and those with significant comorbidity. Despite the significant progress in endovascular abdominal aortic repairing, the EVAR procedure is followed by a nearly fivefold increase in the 30-day reintervention rate as compared to open surgery which comprises 9.8 % according to the EVAR-I, and 18 %, according to the EVAR-II trials.Conclusion. Our multidisciplinary team consisted of vascular and endovascular surgeons managed to perform hybrid surgery, thus eliminating the EVAR-associated complication together with its cause.

Impact assessment of uterine artery embolization on reproductive

Introduction. Uterine artery embolization (UAE) is an effective minimally invasive manipulation that has been widely applied in obstetric and gynecological practice. The expediency of using this method of surgical treatment in patients with reproductive plans is still controversial. The main clinicians' concerns are the risk of developing local endometrial ischemia able to lead to habitual miscarriage, premature birth and pathological placentation as well as decreased ovarian reserve due to impaired adequate ovarian blood supply.Aim: to analyze the literature data regarding UAE effect on reproductive function.Materials and Methods. The search for literature was carried out in databases Web of Science, eLibrary, Scopus, PubMed/MEDLINE. We selected articles for the years 1995–2023 devoted to assessing UAE influence on reproductive function. The articles were searched by the keywords "embolization", "uterine arteries", "reproductive function", "prognosis", "assessment". No methodological filter was used to exclude the omission of suitable articles. The study included full-text sources and literary reviews on the subject under study. Articles that are not directly related to the subject UAE were excluded from the review. In order to avoid the inclusion of duplicate publications if two same author studies were found, the study period of each author was assessed, and if publication dates coincided, the most recent publication was selected.Results. Based on the review of domestic and foreign literature sources over recent years, it can be concluded that there are restrictions on the frequency and outcomes of pregnancy in such cohort of patients who underwent UAE. Many patients included in existing studies and case reports have variable factors complicating direct analysis or comparison such as age of patients, previous spontaneous abortions, previous uterine surgery, different techniques and professional training of X-ray endovascular surgeons, uncertainty of a woman regarding further reproductive plans and other forms of infertility, which can also distort research results. In addition, the most well-controlled studies often have small patients sample sizes not allowing to obtain meaningful clinical information from thereof.Conclusion. Pregnancy is possible in women after UAE, and many of these pregnancies proceed without complications and lead to successful childbirth. The actual fertility rate after UAE remains uncertain, but is approaching 38.3 % based on the available published results.

Physician Modification of a Custom-Made Fenestrated Endograft By Closure of a Fenestration With Bovine Patch.

Ruptured mycotic pararenal aortic aneurysms are rare and serious condition that requires prompt treatment. Open surgery with aortic resection and in-situ or extra-anatomic reconstruction is the standard treatment. The aim of this technical note is to report urgent endovascular treatment using a readily available custom-made device (created for another patient), with a back-table modification using pericardium patch and a new fenestration. In preoperative measurements on centerline-based workstation, aortic diameter in proximal and distal landing zone and target vessel position matched the measurements of graft plan of custom-made device (CMD) besides left renal artery. To address current patient`s anatomy, closure of the nonsuitable fenestration with pericardial patch and creation of new fenestration (1 cm above and 1:15 hours posterior to original fenestration) for the respective target vessel have been performed. Postoperative computed tomography angiography (CTA) scan showed complete exclusion of aneurysm, perfused target vessels, and no endoleak. Under resistance-based antibiotic therapy, the patient was asymptomatic and showed normal infection parameters in blood samples postoperatively. In the hands of an experienced endovascular aortic surgeon modification of a custom-made device is a quick and feasible technique in this emergency situation. Long-term follow-up must confirm the durability and reliability of this new technique. The described technique of modification of a custom-made endograft can provide an alternative endovascular treatment option for urgent complex abdominal aortic pathologies. Compared to the current available treatment modalities, like physician modified endografts, off-the-shelf branched devices, parallel grafts and in-situ fenestration, it can save considerable time and provides reasonable sealing in ruptured cases. The technique offers a valuable add-on to the armamentarium of experienced endovascular physicians.

Prospective Comparison of Wound Complication Rates after Elective Open Peripheral Vascular Surgery - Endovascular Versus Open Vascular Surgeons

Skill and experience of surgeons are likely to influence the incidence of surgical wound complications (SWC) after open lower limb revascularization. Differences in SWC between surgeons with predominantly endovascular or open vascular surgical profiles could be expected. The aim of this study was to compare SWC rates after elective open vascular surgery between primarily endovascular and primarily open vascular surgeons. Prospective data from patients undergoing elective surgery for peripheral artery disease (PAD) was collected between 2013 and 2019. Senior surgeons were assigned to the open-surgeon or the endo-surgeon group based on the percentage of their open surgical case load during the 6year study period. SWC was measured by their clinical impact scale (grade 1-outpatient treatment to grade 6-death). Surgical site infection was defined by Additional treatment, Serous discharge, Erythema, Purulent exudate, Separation of deep tissues, Isolation of bacteria, and Stay (ASEPSIS) criteria. Propensity score adjusted analysis (PSAA) was used to account for differences in baseline and perioperative characteristics and expressed as odds ratios (ORs) with 95% confidence intervals (CIs). The proportion of chronic limb-threatening ischemia (P=0.001), ipsilateral foot wound (P=0.012) and femoro-popliteal bypass procedures (P<0.001) were higher in the open-surgeon group. A lower incidence of SWC according to ASEPSIS criteria (25.6% vs. 38.6%, respectively, P=0.042) and SWC grade ≥1 (33.7% vs. 51.0%, respectively, P=0.010) was found in the endo-surgeon group (n=86) compared to the open-surgeon group (n=153). These differences disappeared after PSAA (OR 0.63, 95% CI 0.27-1.44, and OR 0.60, 95% CI 0.27-1.33, respectively). Patients operated by endo-surgeons had less advanced PAD and lower incidence of SWC compared to those treated by open-surgeons. No difference in SWC remained after PSAA.

Clinical case of a 29 weeks pregnant patient with ST-segment elevation myocardial infarction

HighlightsThis clinical case describes the management of a 29 weeks pregnant patient with myocardial infarction. The material will be useful for cardiologists, physicians, obstetricians and gynecologists, and endovascular surgeons. AbstractUnavoidable drastic changes in lifestyle due childbirth are pushing women to postpone it to an older age, thus increasing the risk of coronary artery disease (CAD) in pregnant women. This can be a problem not only for patients, but also for specialists. Currently there are 3-6 cases of acute coronary syndrome (ACS) per 100 thousand pregnancies, meaning such cases occur rarely in real clinical practice. Discomfort in the chest area does not directly indicate cardiac problem, so women do not visit cardiologist right away, and thus ACS remains undiagnosed. Besides traditional risk factors for CAD (age, dyslipidemia, smoking, physical inactivity), there are some additional obstetric factors: preeclampsia, thrombophilia and postpartum bleeding. About 40% of patients have myocardial infarction in the third trimester. Atherosclerosis is the most common cause of ACS, with coronary artery spasms, coronary artery dissection and thrombosis following behind. Currently the maternal mortality due to MI has decreased from 20% to 5% due to introduction of the percutaneous coronary intervention (PCI) into the treatment of ACS. There are not enough data on the use of thrombolytics and other medicine in the treatment of CAD, because pharmacological therapy can be dangerous in the early pregnancy at the peak of organogenesis. Moreover, PCI should be used with caution due to harmful effects of radiation on the pregnant woman and the fetus. The main task in later stages of pregnancy is to balance out the risk of stent thrombosis upon discontinuing double antiplatelet therapy and bleeding during childbirth and in the postpartum period. This article describes a clinical case of a 29 weeks pregnant patient with myocardial infarction.

Combined use of percutaneous and endovascular surgery in the diagnosis and treatment of arteriovenous malformation of the kidneys. Clinical observation

This article describes the causes of vascular abnormality of the upper urinary tract, arteriovenous malformation of the kidneys, its variants, possible clinical manifestations, methods of diagnosis of this condition, as well as ways to eliminate hemorrhagic complications caused by this pathology. The main method of correction of arteriovenous malformation is superselective embolization of vessels of the malformation zone. This clinical example presents a rare case of surgery in which embolization was unacceptable due to technical difficulties associated with the complexity of vascular angioarchitectonics, with the impossibility of superselective entry into varix through the arterial channel. In this regard, endovascular surgeons and urologists had to use a combined approach – percutaneous varix puncture with the introduction of a spiral and an embolizing substance through a puncture needle under the control of selective angiography of the branches of the renal artery.

A Case Series of Late Vascular Lesions of Traumatic Etiology: Endovascular and Surgical Approaches.

There is a broad spectrum of pathology in traumatic vascular injury. Arteriovenous fistula (AVF) is an abnormal communication between the high-flow arterial system and the low-flow venous network, directly connecting the afferent artery and nearby draining veins without the regular intervention of the capillary bed. Most of these fistulas occur due to incidental or iatrogenic injury. A retrospective review of procedures performed by an endovascular surgeon in a tertiary center identified 15 cases of vascular injuries that encompassed all these different clinical scenarios, including post-traumatic, iatrogenic, or spontaneous origin. The information collected, including patient age, sex, previous symptoms, and treatment, was gathered from medical records. In addition, information on procedural technique, endovascular devices used, and specific intraprocedural details were collected from procedure notes and angiographic images. A broad spectrum of injuries can present as late trauma complications (over three months); endovascular treatment is a safe and effective approach for intracranial and extracranial injuries. Endovascular treatment can be a sole option or adjuvant to other hybrid therapies and has emerged as essential for treating these lesions as a first option. We have described standard techniques to treat different vascular pathologies, sometimes with limited resources.

Predicting Features of Visceral Stent Failure in Fenestrated Endovascular Aortic Aneurysm Repair.

Visceral stents in fenestrated endovascular aortic repair (FEVAR) have a significant risk of complications and carry a considerable burden of reinterventions. The aim of this study is to identify preoperative and intraoperative predictors of visceral stent failure. A retrospective review of 75 consecutive FEVARs in a single center from 2013 to 2021 was undertaken. Data on mortality, stent failure, and reintervention pertaining to 226 visceral stents were collected. Anatomical features including aortic neck angulation, aneurysm diameter, and angulation of target viscerals were obtained from preoperative computed tomography (CT) scans. Stent oversizing and intraprocedural complications were recorded. Postoperative CT scans were analyzed to determine the length of cover of target vessels. Only bridging stents through fenestrations to visceral vessels were considered; 28 (37%) cases had 4 visceral stents, 24 (32%) had 3, 19 (25%) had 2, 4 (5%) had 1. Thirty day mortality was 8%, a third of which was related to visceral stent complications. Intraprocedural complexity was documented during the cannulation of 8 (3.5%) target vessels, with a technical success rate of 98.7%. A significant endoleak or visceral stent failure was identified in 22 stents (9.8%) postoperatively, of which 7 (3%) had in-patient reintervention within 30 days. Further reinterventions at 1, 2, and 3 years were 12 (5.4%), 2 (1%), and 1 (0.4%), respectively. Most reinterventions were for renal stents (n=19, 86%). A smaller stent diameter and a shorter length of visceral stent were significant predictors of failure. No other anatomical feature or stent choice was found to be a significant predictor of failure. The modality of visceral stent failures varies, but renal stents with a smaller diameter and/or shorter length are more likely to fail over time. Their complications and reinterventions are common and carry a significant burden; therefore, close surveillance must be continued long term. With this work we share the methodology adopted at our centre to treat juxtarenal aneurysm with FEVAR. Thanks to this detailed review of anatomical and technical features we provide guidance for endovascular surgeons to face hostile aneurysm with peculiar visceral vessels anatomy. With our findings will also motivate industries in their attempt to produce improved technologies able to overcome issues identified in this paper.