1,720,970 research outputs found
Sarcoma of the Thigh: Radical Excision with Arterial Reconstruction Using the Contralateral Saphenous Vein
No full textSoft tissue sarcomas are a heterogeneous group of malignant mesenchymal neoplasms that frequently affect large muscle of the thigh. A conservative limb-salvage surgery involving en bloc resection of the whole tumor with surrounding healthy tissue can sometimes be considered instead of amputation to achieve good local disease control while preserving a satisfying function of the
affected limb.
The massive vascular encasement, once regarded as a contraindication to limb-salvage surgery, can sometimes be
encompassed thanks to vascular axis reconstruction.
Although no doubt exists about the need for reconstruction of the femoral artery with quite good reported results, the
venous replacement is a controversial issue with unclear patency rates, yet this replacement is mandatory when
superficial and deep femoral veins are removed together with the saphenous vein. The femoral artery is commonly
replaced with an autologus reversed saphenous vein graft because of its resistance to infections and its excellent
patency rates compared with artificial grafts.
We present a case of thigh sarcoma involving the femoral vascular axis with complete clogging of the
femoral vein due to massive deep thrombosis. The video illustrates the features of the case and highlights the steps
of a wide compartment resection with arterial reconstruction by autologus reversed saphenous vein graft
New technical approach for type B dissection: from the PETTICOAT to the STABILISE concept
No full textEndovascular treatment of acute complicated type B aortic dissection (TBD) has recently acquired a primary therapeutic role when anatomically feasible. However, strategies meant to simply close the proximal entry tear leave the risk of persistent perfusion of the false lumen(FL) through additional tears in the thoracoabdominal aorta, and therefore the potential for aneurysmal degeneration remains significant over the years. Thus, additional bare stent implantation in the thoracoabdominal aorta has been proposed to promote true lumen (TL)expansion, malperfusion relief, and intimal lamella stabilization. This technique, also known as the Provisional Extension To Induce Complete Attachment Technique (PETTICOAT) offers good short- and mid-term results, but some degree of perfusion of the FL is still maintained, and the aorta showed a tendency to grow distally to the stent-graft. An evolution of PETTICOAT, mainly including aggressive ballooning of the covered stent-graft and of the distal bare stents deployed in the TL, in order to obtain full expansion of the stents in a single channeled aorta, has been proposed in 2012 and named Stent-Assisted Balloon-Induced Intimal Disruption and Relamination in Aortic Dissection Repair (STABILISE) technique. Although this approach produced excellent early results in single-center series, it did not gain immediate acceptance in the community, mainly because of concerns regarding the potential risk of rupturing the aorta during ballooning. In this review, we summarize the current evidence on the results of these strategies, we present a recently modified approach of the STABILISE technique, and report the early results in a cohort of patients treated in the last two years at our institution
A systematic review of infected descending thoracic aortic grafts and endografts
No full textObjective: The objective of this study was to collect and critically analyze the current evidence on the modalities and results of treatment of descending thoracic aortic surgical graft (SG) and endograft (EG) infection, which represents a rare but dramatic complication after both surgical and endovascular aortic repair. Methods: A comprehensive electronic health database search (PubMed/MEDLINE, Scopus, Google Scholar, and the Cochrane Library) identified all articles that were published up to October 2017 reporting on thoracic aortic SG or EG infection. Observational studies, multicenter reports, single-center series and case reports, case-control studies, and guidelines were considered eligible if reporting specific results of treatment of descending thoracic aortic SG or EG infection. Comparisons of patients presenting with SG or EG infection and between invasive and conservative treatment were performed. Odds ratio (OR) meta-analyses were run when comparative data were available. Results: Forty-three studies reporting on 233 patients with infected SG (49) or EG (184) were included. Four were multicenter studies including 107 patients, all with EG infection, associated with a fistula in 91% of cases, with a reported overall survival at 2 years of 16% to 39%. The remaining 39 single-center studies included 49 patients with SG infection and 77 with EG infection. Association with aortoesophageal fistula was significantly more common with EG (60% vs 31%; P = .01). In addition, time interval from index procedure to infection was significantly shorter with EG (17 +/- 21 months vs 32 +/- 61 months; P = .03). Meta-analysis showed a trend of increased 1-year mortality in patients with SG infection compared with EG infection (pooled OR, 3.6; 95% confidence interval, 0.9-14.7; P = .073). Surgical management with infected graft explantation was associated with a trend toward lower 1-year mortality compared with graft preservation (pooled OR, 0.3; 95% confidence interval, 0.1-1.0; P = .056). Conclusions: Thoracic aortic EG infection is likely to occur more frequently in association with aortoesophageal fistulas and in a shorter time compared with SG infection. Survival is poor in both groups, especially in patients with SG infection. Surgical treatment with graft explantation seems to be the preferable choice in fit patients
Open or endovascular treatment of downstream thoracic or thoraco-abdominal aortic pathology after frozen elephant trunk: perioperative and mid-term outcomes
No full text: Objectives: The aim of this study was to evaluate the outcomes of open and endovascular treatment of downstream thoracic or thoraco-abdominal aortic pathology in patients who underwent previous frozen elephant trunk (FET). Methods: Data were retrieved to evaluate mortality, cardiac, pulmonary, cerebrovascular, renal and spinal cord major adverse events, early- and mid-term reintervention and survival rates. The Society for Vascular Surgery endovascular reporting standards were used. Results: From 2011 to 2020, 48 patients (36 males, median age 60 years) underwent downstream aortic repair at a median of 18 months (interquartile range: 6-57) after the initial FET. Twenty-eight patients (58.3%) received open and 20 (41.7%) endovascular repair. The overall 30-day mortality was 6.3% and the initial clinical success was 88%, with no inter-group differences (P = 0.22 and 0.66 respectively). Six spinal cord deficits were recorded (13%): 3 (6.3%) were permanent. The major adverse events incidence was lower in the endovascular cohort [4 (20%) vs 14 (50%); P = 0.047], mainly due to a lower rate of grade ≥2 respiratory complications (5% vs 42.9%; P = 0.004). Assisted primary clinical success at 5 years was higher in the endovascular group (95% vs 68%, P = 0.022); freedom from reintervention at competing risk analysis (P = 0.3) and overall survival at Kaplan-Meier curves (log-rank P = 0.29) were similar. Conclusions: Downstream aortic repair after FET is feasible with both open and endovascular repair with acceptable mortality and permanent paraplegia rates. The endovascular approach has potential perioperative and mid-term advantages, but long-term durability has to be further investigated in larger cohorts
Fourteen-Year Outcomes of Abdominal Aortic Endovascular Repair With the Zenith Stent Graft
No full textObjectives
Long-term results of abdominal aortic aneurysm (AAA) endovascular repair (EVAR) are affected by graft design renewals that tend to improve performances of older generations but usually reset follow-up times to zero. The present study investigated long-term outcomes, up to 14 years, of EVAR using the Zenith graft (Cook Medical, Bloomington, Ind), still in use without major modification, in a single-center experience.
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Methods
Between 2000 and 2011, 610 patients representing the study group underwent elective EVAR using the Zenith endograft. Primary outcomes were overall survival, freedom from AAA rupture, and freedom from AAA-related death. Secondary outcomes included freedom from late reintervention, late conversion to open repair, aneurysm sac enlargement >5.0 mm, and EVAR failure (a composite of AAA-related death, AAA rupture, AAA growth, and any reintervention).
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Results
Mean age was 73.2 years. Mean aneurysm diameter was 55.3 mm. Mean proximal neck length was 24.7 and diameter was 23.9 mm. There were 5 perioperative deaths (0.8%), and 3 intraoperative conversions. At a mean follow-up of 99.2 months (range 0-175), 7 AAA ruptures occurred, all fatal except one. Overall survival, by Kaplan-Meier analysis, was 92.8% ± 1.1% at 1 year, 37.8% ± 2.9% at 10 years, and 24% ± 4% at 14 years. Freedom from AAA rupture was 99.8% ± 0.02 at 1 year and 98.1% ± 0.07% at 10 and 14 years. Freedom from AAA-related death was 99.2% ± 0.4% at 1 year, and 97.3% ± 0.8% at 10 and 14 years. Freedom from late reintervention and conversion was 98% ± 0.6% at 1 year, 87.7% ± 1.5% at 5 years, 75.7% ± 3.2% at 10 years, and 69.9% ± 5.2% at 14 years. Freedom from aneurysm sac growth >5.0 mm was 99.8% at 1 year, 81.0% ± 3.4% at 10 years, and 74.1% ± 5.8% at 14 years. EVAR failure occurred in 132 patients(21.6%) at 14 years. At multivariate analysis, independent predictors of EVAR failure were type I and III endoleak (hazard ratio [HR], 10.8; 95% confidence interval [CI], 7.2-16; P ≤ .001), type II endoleak (HR, 3.59; 95% CI, 2.5-5.5; P < .001), and ASA grade 4 (HR, 1.55; 95% CI, 1.0-2.6; P = .031).
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Conclusions
Our 14-year experience shows that EVAR with Zenith graft provides a safe and durable repair. Risk of rupture and aneurysm-related death is low, while overall long-term survival remains poor. Novel endograft models should be tested and evaluated considering that one-fourth of the operated patients will still be alive after 14 years
Intravascular Ultrasound Imaging and Endovascular Treatment of Left Ventricle Assist Device (HM3) Outflow Graft Obstruction
No full textPreliminary Outcomes of the LifeStream Balloon-Expandable Covered Stent in Fenestrated and Branched Thoracoabdominal Endovascular Repairs
No full textTo evaluate the 1-year outcomes of thoracoabdominal aortic aneurysm (TAAA) repair using fenestrated and branched stent-grafts and a novel balloon-expandable covered stent
How to best treat infectious complications of open and endovascular thoracic aortic repairs
No full textInfectious complications of open and endovascular procedures for descending thoracic aortic disease are relatively rare, affecting 1% to 6% of treated patients. However, the number of thoracic aortic procedures, especially endovascular, is increasing continuously, and infectious complications involving the graft or endograft have been observed more frequently in recent years. Several causative factors may play a role in thoracic aortic prosthetic infections, including hematogenous seeding, local bacterial translocation, and iatrogenous contamination. In addition, the development of a fistula between the aortic graft and the esophagus or the bronchial tree is a common associated finding, representing a dramatic event that further increases mortality rates and requires multidisciplinary management. Treatment of these conditions is demanding, often including a number of pharmacological, surgical, and endovascular options. Because there are several different surgical strategies and timing modalities that are chosen according to the surgeon's experience, the results of different treatment options are difficult to summarize, and no consensus exists on a standardized paradigm of treatment. In this review, published reports regarding clinical outcomes related to thoracic graft and endograft infections are discussed, including our personal experience with surgical and endovascular management of this condition
Suitability of current off-the-shelf devices for endovascular TAAA repair: a systematic review
No full textIntroduction: The aim of the present study is to perform a systematic review of published papers regarding the suitability of the current off-the-shelf (OTS) devices for endovascular thoracoabdominal aortic aneurysm (TAAA) repair. Evidence acquisition: A systematic review of the MEDLINE database via PubMed was performed in March 2023. All studies reporting the outcomes of the three currently available OTS stent-grafts: the Zenith t-Branch (Cook Medical, Bloomington, IN, USA), the Gore Excluder thoracoabdominal branch endoprosthesis (TAMBE; W.L. Gore & Associates, Flagstaff, AZ, USA) and the E-nside Multibranch Stent-Graft System (Artivion, Kennesaw, GA, USA), were retrieved and further analyzed. The main endpoints were technical success, reintervention rate, and primary branch patency. Theoretical feasibility studies of these OTS devices were also included and separately analyzed. Evidence synthesis: A total of 19 studies were published between 2014 and 2023. Thirteen clinical studies and six theoretical feasibility studies were included. Eleven studies reported the clinical outcomes of the t-Branch stent-graft, one detailed the observational results of the use of the E-nside endoprosthesis, and one described the TAMBE stent-graft results. The following data primarily involve the t-Branch device outcomes. A total of 1131 patients that underwent aneurysm repair using an OTS stent-graft were identified. Among those, 1002, 116 and 13 patients received a t-Branch, E-nside, and TAMBE stent-grafts, respectively. A total of 767 (67.8%) were men, with a mean age of 71.6±7.4 years old, and a mean Body Mass Index (BMI) of 26.3±3.8 kg/m2. Technical success ranged from 64% to 100%. A total of 4172 target visceral vessels (TVV) were planned for bridging, with a success rate ranging from 92 to 100%. The total of early and late reinterventions reported were 64 and 48, respectively, mainly due to endoleaks and visceral branch occlusions. Among the theoretical feasibility studies, six described the feasibility of the t-Branch device in a total of 661 patients, two described the E-nside and the TAMBE devices feasibility comprising 351 patients for each stent-graft. The overall feasibility of the t-Branch device varied from 39% to 88%, the E-nside from 43% to 75%, and the TAMBE stent-graft ranged from 33% to 94%. Conclusions: This systematic review demonstrated a good suitability for the use of OTS endografts for the treatment of TAAA. A systematic review of the MEDLINE database via PubMed was performed in March 2023. All studies reporting the outcomes of the three currently available OTS stent-grafts: the Zenith t-Branch (Cook Medical, Bloomington, IN, USA), the Gore Excluder thoracoabdominal branch endoprosthesis (TAMBE; W.L. Gore & Associates, Flagstaff, AZ, USA) and the E-nside Multibranch Stent-Graft System (Artivion, Kennesaw, GA, USA), were retrieved and further analyzed. The main endpoints were technical success, reintervention rate, and primary branch patency. Theoretical feasibility studies of these OTS devices were also included and separately analyzed. CONCLUSIONS: This systematic review demonstrated a good suitability for the use of OTS endografts for the treatment of TAAA
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