18 research outputs found
Choose the appropriate access route in bovine arch and you will turn a complex left carotid artery stenting procedure into a simple one
No full textA Tailored Approach to Overcoming Challenges of a Bovine Aortic Arch During Left Internal Carotid Artery Stenting
No full textPurpose: To investigate the efficacy and safety of a tailored approach to fit access and engagement techniques to the individual arch anatomy in patients with bovine-type aortic arch (BTAA) to overcome the perceived increased risk of technical failure and cerebral embolization during left internal carotid artery (LICA) stenting. Methods: Thirty-five high surgical risk patients (23 men; mean age 68.6 years, range 62-90) with BTAA and LICA stenosis underwent carotid artery stenting (CAS). Left common carotid artery (LCCA) engagement was achieved by means of different techniques according to the configuration of the BTAA, arch type (I, II, or III), and angle between the innominate artery and the LCCA. The clinical, anatomical, and procedural data were retrieved from a prospectively maintained database and analyzed retrospectively to identify technical modifications required during the procedure compared with planning. Results: The technical success rate was 100%. Transfemoral access was used in 21 (60%) cases. In this group, the soft engagement technique with hockey stick (HS) guiding catheter and buddy wire in the external carotid artery (ECA) was used in 13 (62%) cases, a simple telescopic technique with 6-F armed introducer or 7-F 40 degrees guiding catheter in 5 (24%) cases, and a sequential technique with a MOMA proximal protection system in the remaining 3 (14%) cases. Among the 14 (40%) right brachial access cases, the telescopic technique with 6-F armed introducer was used in 13 cases. The remaining case was the only one in which the planned technique was changed (from the telescopic to sequential technique with ECA wire exchange). There were no intraprocedural or 30-day neurological events. Conclusion: An appropriate tailored interventional strategy, planned by means of preprocedural recognition of bovine arch anatomy, is associated with satisfactory safety and good success. J Endovasc Ther. 2012;19:329-33
Limb Salvage and Survival in Chronic Limb-Threatening Ischemia: The Need for a Fast-Track Team-Based Approach
No full textChronic limb-threatening ischemia (CLTI) represents the end-stage form of peripheral arterial disease (PAD) and is associated with a very poor prognosis and high risk of limb loss and mortality. It can be considered very similar to a terminal cancer disease, reflecting a large impact on quality of life and healthcare costs. The aim of this study is to offer an overview of the relationship between CLTI, limb salvage, and mortality, with a focus on the need of a fast-track team-based management that is a driver to achieve better survival results. This review can be useful to improve management of this growing impact disease, and to promote the standardisation of care and communication between specialist and non-specialist healthcare professionals
TCT-343 Paclitaxel Drug Eluting Balloon Versus Standard Angioplasty To Reduce Restenosis In Diabetic Patients With In Stent Restenosis Of The Superficial Femoral And Proximal Popliteal Artery
No full textIndications and Results of Endovenous Laser Treatment of Saphenous Incompetence
No full textINTRODUZIONE: il trattamento laser endovenoso (TLE) è stato recentemente prorposto come una alternativa al trattamento chirurgico tradizionale dell’incontinenza della vena grande safena (VGS) e vena piccola safena (VPS). Riportiamo la nostra esperienza preliminare nello stabilire la sicurezza, efficacia, le indicazioni e i risultati di questa nuova tecnica endovenosa.
MATERIALI E METODI: 21 VGS e 3 VPS in 24 patienti (82% F, 18% M) con incontinenza safenica clinicamente evidente sono stati trattati in un periodo di 5 mesi con energia laser diodica 940-nm, rilasciata nella VGS e VPS attraverso una fibra ottica di 600-µm, e valutati in uno studio monocentrico, prospettico, non randomizzato. L’accesso venoso per il posizionamento endoluminale della fibra attraverso un introduttore è stato ottenuto per via percutanea o mediante accesso chirurgico tramite uncino di Muller in anestesia locale. Una anestesia per tumescenza (AT) con 100–200 mL di lidocaina 0.2% è stata praticata intorno alla vena sotto guida ecografica. L’energia laser è stata emessa utillizzando una Potenza di 15 W in emissione continua con una velocità di retrazione della fibra di 1-3 mm/sec in modo da erogare intorno ai 60-80 J/cmL nella VGS e intorno ai 40-60 J/cmL nella VPS. I pazienti sono stati valutati clinicamente e ecograficamente a 1 settimana, 1-3-6-12 e 16 mesi per stabilire l’efficacia del trattamento e le eventuali complicanze.
RISULTATI: il Follow-up (FU) è compreso fra 12 e 16 (FU medio di 13,8 mesi ; DS di 1,5 mesi). Successo tecnico e obliterazione venosa, definita dall’assenza di flusso al controllo ecografico, è stato ottenuto nel 100% dei tronchi safenici trattati. Si è osservata una recidiva su 21 VGS trattate (4,8%), evidenziata al 3° mese di FU, a partenza da un affluente incontinente della “crosse” safenica. Le ecchimosi, presenti in 8 su 24 (33,3%) pazienti si sono risolte in tutti i soggetti prima di 1 mese. 20 su 24 (83%) pazienti hanno descritto una sensazione di “stiramento” lungo il decorso della vena trattata di massima intensità in IV-VII giornata. Non si sono osservate ustioni cutanee da calore, trombosi venose superficiali e profonde o altre complicanze maggiori eccetto 4 parestesie di coscia su 21 VGS trattate (19%) risolte tutte in 6 mesi. Questa complicanza si è verificata solo nel primo gruppo di 6 VGS trattate con anestesia locale assistita senza utilizzo di AT.
CONCLUSIONI: il TLE dell’incontinenza safenica sembra essere una tecnica mini-invasiva sicura ed efficace alternativa alla chirurgia tradizionale in pazienti selezionati. Trials randomizzati e su grandi numeri sono necessari per stabilire l’efficacia a lungo termine e definire ulteriormente il ruolo di questa nuova promettente tecnica endovenosa
One-year experience of a regional service model of teleconsultation for planning and treatment of complex thoracoabdominal aortic disease
No full textObjective: The objective of this study was to report the methodology and 1-year experience of a regional service model of teleconsultation for planning and treatment of complex thoracoabdominal aortic disease (TAAD). Methods: Complex TAADs without a feasible conventional surgical repair were prospectively evaluated by vascular surgeons of the same public health service (National Health System) located in a huge area of 22,994 km2with 3.7 million inhabitants and 11 tertiary hospitals. Surgeons evaluated computed tomography scans and clinical details that were placed on a web platform (Google Drive; Google, Mountain View, Calif) and shared by all surgeons. Patients gave informed consent for the teleconsultation. The surgeon who submits a case discusses in detail his or her case and proposes a possible therapeutic strategy. The other surgeons suggest other solutions and options in terms of grafts, techniques, or access to be used. Computed tomography angiography, angiography, and clinical outcomes of cases are then presented at the following telemeetings, and a final agreement of the operative strategy is evaluated. Teleconsultation is performed using a web conference service (WebConference.com; Avaya Inc, Basking Ridge, NJ) every month. An inter-rater agreement statistic was calculated, and the Îo value was interpreted according to Altman's criteria for computed tomography angiography measurements. Results: The rate of participation was constant (mean number of surgeons, 11; range, 9-15). Twenty-four complex TAAD cases were discussed for planning and operation during the study period. The interobserver reliability recorded was moderate (Îo = 0.41-0.60) to good (Îo = 0.61-0.80) for measurements of proximal and distal sealing and very good (Îo = 0.81-1) for detection of any target vessel angulation >60 degrees, significant calcification (circumferential), and thrombus presence (>50%). The concordance for planning and therapeutic strategy among all participants was complete in 16 cases. In one case, the consultation was decisive for creating an innovative therapeutic strategy; in the remaining seven cases, the strategy proposed by the patient's surgeon was changed completely after the discussion. Technical success was the same (100%) if concordance in planning was present initially or not. Overall 6-month mortality was 4%, 0% for those patients with initial concordance in planning vs 12% for those without initial concordance (P =.33). Surgery was always performed in a tertiary hospital by local surgeons, and in two cases (8%) external surgeons joined the local surgical team. Conclusions: Such a regional service of teleconsultation may be of value in standardizing the treatment and derived costs of complex TAADs in a huge region under the same health provider. The shared decision-making strategy may be of medical-legal value as well
TCT-343 Paclitaxel Drug Eluting Balloon Versus Standard Angioplasty To Reduce Restenosis In Diabetic Patients With In Stent Restenosis Of The Superficial Femoral And Proximal Popliteal Artery
No full textTransrenal E-XL stenting to resolve or prevent type Ia endoleak in the case of severe neck angulation during endovascular abdominal aortic aneurysm repair
No full textDuring endovascular abdominal aortic aneurysm repair, a severely angulated neck can make proximal sealing of endografts challenging, and the occurrence of a type Ia endoleak can complicate the procedure. We describe an original adjunctive procedure involving transrenal placement of a self-expanding nitinol stent (E-XL aortic stent; Jotec GmbH, Hechingen, Germany) to remodel the proximal aortic neck and treat or prevent type Ia endoleaks in the case of severe angulation of the proximal neck
Bypass surgery versus endovascular revascularization for occlusive infrainguinal peripheral artery disease: a meta-analysis of randomized controlled trials for the development of the Italian Guidelines for the treatment of diabetic foot syndrome
No full textTo report a review and meta-analysis of all randomized controlled trials (RCTs) comparing bypass surgery (BS) and endovascular treatment (ET) in infrainguinal peripheral arterial disease (PAD) for several endpoints, such as major and minor amputation, major adverse limb events (MALEs), ulcer healing, time to healing, and all-cause mortality to support the development of the Italian Guidelines for the Treatment of Diabetic Foot Syndrome (DFS). A MEDLINE and EMBASE search was performed to identify RCTs, published since 1991 up to June 21, 2023, enrolling patients with lower limb ischemia due to atherosclerotic disease (Rutherford I-VI). Any surgical BS or ET was allowed, irrespective of the approach, route, or graft employed, from iliac to below-the-knee district. Primary endpoint was major amputation rate. Secondary endpoints were amputation-free survival major adverse limb events (MALEs), minor amputation rate, all-cause mortality, ulcer healing rate, time to healing, pain, transcutaneous oxygen pressure (TcPO2) or ankle-brachial index (ABI), quality of life, need for a new procedure, periprocedural serious adverse events (SAE; within 30 days from the procedure), hospital lenght of stay, and operative time. Twelve RCTs were included, one enrolled two separate cohorts of patients, and therefore, the studies included in the analyses were 13. Participants treated with ET had a similar rate of major amputations to participants treated with BS (MH-OR 0.85 [0.60, 1.20], p = 0.36); only one trial reported separately data on patients with diabetes (N = 1), showing no significant difference between ET and BS (MH-OR: 0.67 [0.09, 5.13], p = 0.70). For minor amputation, no between-group significant differences were reported: MH-OR for ET vs BS: 0.83 [0.21, 3.30], p = 0.80). No significant difference in amputation-free survival between the two treatment modalities was identified (MH-OR 0.94 [0.59, 1.49], p = 0.80); only one study reported subgroup analyses on diabetes, with a non-statistical trend toward reduction in favor of ET (MH-OR 0.62 [0.37, 1.04], p = 0.07). No significant difference between treatments was found for all-cause mortality (MH-OR for ET vs BS: 0.98 [0.80, 1.21], p = 0.88). A significantly higher rate of MALE was reported in participants treated with ET (MH-OR: 1.44 [1.05, 1.98], p = 0.03); in diabetes subgroup analysis showed no differences between-group for this outcome (MH-OR: 1.34 [0.76, 2.37], p = 0.30). Operative duration and length of hospital stay were significantly shorter for ET (WMD: - 101.53 [- 127.71, - 75.35] min, p < 0.001, and, - 4.15 [- 5.73, - 2.57] days, p < 0.001 =, respectively). ET was associated with a significantly lower risk of any SAE within 30 days in comparison with BS (MH-OR: 0.60 [0.42, 0.86], p = 0.006). ET was associated with a significantly higher risk of reintervention (MH-OR: 1.57 [1.10, 2.24], p = 0.01). No significant between-group differences were reported for ulcer healing (MH-OR: 1.19 [0.53, 2.69], p = 0.67), although time to healing was shorter (- 1.00 [0.18, 1.82] months, p = 0.02) with BS. No differences were found in terms of quality of life and pain. ABI at the end of the study was reported by 7 studies showing a significant superiority of BS in comparison with ET (WMD: 0.09[0.02; 0.15] points, p = 0.01). The results of this meta-analysis showed no clear superiority of either ET or BS for the treatment of infrainguinal PAD also in diabetic patients.Further high-quality studies are needed, focusing on clinical outcomes, including pre-planned subgroup analyses on specific categories of patients, such as those with diabetes and detailing multidisciplinary team approach and structured follow-up
Drug-Eluting Balloon in Peripheral Intervention for the Superficial Femoral Artery The DEBATE-SFA Randomized Trial (Drug Eluting Balloon in Peripheral Intervention for the Superficial Femoral Artery)
No full textObjectivesThis study sought to compare paclitaxel-eluting balloon (PEB) with conventional percutaneous transluminal angioplasty (PTA), followed by systematic implantation of a self-expanding nitinol bare-metal stent (BMS) in patients at risk for restenosis.BackgroundPTA is an effective strategy for treating atherosclerosis of the femoropopliteal axis (FPA). Whereas PEB have shown advantage over uncoated balloons in the treatment of simple lesions, it is unknown whether these results are applicable to complex degrees of FPA atheroma.MethodsA total of 104 patients (110 FPA lesions in 110 limbs) were randomly assigned to either PEB + BMS or PTA + BMS. The primary endpoint was 12-month binary restenosis. Secondary endpoints were freedom from target lesion revascularization and major amputation. Post hoc subanalyses were performed for the comparison of long (≥100 mm) versus short lesions and true lumen versus subintimal approach.ResultsMean lesion length was 94 ± 60 versus 96 ± 69 mm in the PEB + BMS and PTA + BMS groups (p = 0.8), respectively. The primary endpoint occurred in 9 (17%) versus 26 (47.3%) of lesions in the PEB + BMS and PTA + BMS groups (p = 0.008), respectively. A near-significant (p = 0.07) 1-year freedom from target lesion revascularization advantage was observed in the PEB + BMS group. No major amputation occurred. No significant difference was observed according to lesion characteristics or technical approach.ConclusionsPre-dilation with PEB angioplasty prior to BMS implantation, as compared to PTA + BMS in complex FPA lesions, reduces restenosis and target lesion revascularization at 12-month follow-up. Restenosis reduction is maintained irrespective of lesion length and recanalization technique. (Drug Eluting Balloon in Peripheral Intervention for the Superficial Femoral Artery [DEBATE-SFA]; NCT01556542
