Malformation of the thoracic aorta associated to aneurysms of the arch: an extraanatomic surgical approach.
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Biomedical subjects
Giovanni P Deriu
Publications and source records attributed to Giovanni P Deriu.
Is contralateral carotid artery occlusion a risk factor for carotid endarterectomy?
Occlusion of the contralateral internal carotid artery (ICA) is considered to have a significant impact on the outcome of carotid endarterectomy (CEA). The purpose of this study was to review one center's experience concerning CEA opposite an occluded ICA, to see whether results differed from those obtained in patients with patent contralateral ICA in terms of relevant neurologic complication rate (RNCR, fatal + disabling stroke), stroke-free rate, and survival rate. From January 1997 to December 2002, 1,381 patients underwent a total of 1,445 CEAs at the Department of Vascular Surgery of Padua University. Patients were divided into two groups: group A included 144 patients with occlusion of the contralateral ICA and group B consisted of 1,237 patients with a patent contralateral ICA. There was no postoperative mortality in patients of group A, while in group B, two patients died as a result of myocardial infarction and cardiac failure and one died as a direct result of perioperative stroke. Postoperative disabling strokes occurred in one (0.7%) patient in group A and 10 (0.8%) patients in group B (p > 0.5). At 72 months, there were no statistical differences between the two groups in terms of RNCR, stroke-free rate, and late death. Our results show that contralateral carotid occlusion does not reduce the safety of CEA. The efficacy in terms of RNCR, stroke-free rate, and late survival is no different in patients with contralateral carotid occlusion.
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Open repair versus endovascular treatment for asymptomatic popliteal artery aneurysm: results of a prospective randomized study.
PURPOSE: The aim of this prospective randomized study was to evaluate the relative risks and advantages of using the Hemobahn graft for popliteal artery aneurysm (PAA) treatment compared with open repair (OR). The primary end point was patency rate; secondary end points were hospital stay and length of surgical procedure. METHODS: The study was a prospective, randomized clinical trial carried out at a single center from January 1999 to December 2003. Inclusion criteria were an aneurysmal lesion in the popliteal artery with a diameter > or = 2 cm at the angio-computed tomography (CT) scan, and proximal and distal neck of the aneurysm with a length of > 1 cm to offer a secure site of fixation of the stent graft. Exclusion criteria were age < 50 years old, poor distal runoff, contraindication to antiplatelet, anticoagulant, or thrombolytic therapy, and symptoms of nerve and vein compression. The enrolled patients were thereafter prospectively randomized in a 1-to-1 ratio between OR (group A) or endovascular therapy (ET) (group B). The follow-up protocol consisted of duplex ultrasound scan and ankle-brachial index (ABI) measured during a force leg flexion at 1, 3, and 6 months. Group B patients underwent an angio-CT scan and plain radiography of the knee with leg flexion (> 120 degrees) at 6 and 12 months, and then yearly. RESULTS: Between January 1999 and December 2003, 30 PAAs were performed: 15 OR (group A) and 15 ET (group B). Bypass and exclusion of the PAA was the preferred method of OR; no perioperative graft failure was observed. Twenty stent grafts were placed in 15 PAAs. Endograft thrombosis occurred in one patient (6.7%) in the postoperative period. The mean follow-up period was 46.1 months (range, 12 to 72 months) for group A and 45.9 months (range, 12 to 65 months) for group B. Kaplan-Meier analysis showed a primary patency rate of 100% at 12 months for OR and 86.7% at 12 months with a secondary patency rate of 100% at 12 and 36 months for ET. No statistical differences were observed at the log-rank test. The mean operation time (OR, 155.3 minutes; ET, 75.4 minutes) and hospital stay (OR, 7.7 days; ET, 4.3 days) were statistically longer for OR compared with ET (P < .01). CONCLUSION: We can conclude, with the power limitation of the study, that PAA treatment can be safely performed by using either OR or ET. ET has several advantages, such as quicker recovery and shorter hospital stay.
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Popliteal-to-distal bypass for limb salvage.
A retrospective study was carried out to examine the patency and limb salvage rates of popliteal-to-distal bypass and compare the results of diabetic to those of nondiabetic patients and elective versus emergency procedures. From January 1990 to December 2001, 71 popliteal-to-distal bypasses were performed. Indications for surgery were rest pain, tissue loss, and acute ischemia, including extensive post-traumatic tibial lesions. Survival, graft patency, and limb salvage rates were determined according to the life-table method. The log-rank test was used to compare diabetic versus nondiabetic patients, elective versus emergency procedures, and saphenous vein bypass versus PTFE bypass. Postoperative primary patency, secondary patency, and limb salvage rates at 30 days were 88.7%, 91.4%, and 87%, respectively. Postoperative mortality was 2.8%, with one case of acute myocardial ischemia and one multiorgan failure. Life-table analysis showed primary and secondary patency rates of 57% and 61%, respectively, a limb salvage rate of 64%, and survival of 77% at 5 years Log-rank testing showed no statistical difference between diabetic and nondiabetic patients, whereas a statistical difference was observed in elective versus emergency procedures (p < 0.005) and great saphenous vein versus PTFE graf (p < 0.05). These results show that popliteal-to-distal bypass is a safe and effective procedure with good long-term patency and limb salvage rates in selected cases.
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Primitive proatlantal intersegmental artery and carotid endarterectomy.
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Suprarenal fixation of endograft in abdominal aortic aneurysm treatment: focus on renal function.
OBJECTIVE: The objective of this work was to evaluate any variation of renal function detected by renal scintigraphy after the suprarenal fixation of endografts for abdominal aortic aneurysm (AAA) repair. SUMMARY BACKGROUND DATA: In the few articles that have considered this problem, renal function was evaluated only by biochemical tests, which are inadequate in demonstrating small changes in renal function and in appreciating the worsening of a single kidney's function. METHODS: Between April 1999 and May 2002, 47 patients with an inappropriate infrarenal proximal neck had a suprarenal fixation for AAA. To assess renal function, a technetium-99m diethylene triamine penta-acetic acid (TC-DTPA) perfusion scintigraphy was performed preoperatively on the third postoperative day and at 6, 12 months, and then yearly thereafter. Worsening of renal function was defined as a decrease of glomerular filtration rate (GFR) > or =20% (detected with Gates method). Serum creatinine level was tested preoperatively and at the first and third postoperative day. RESULTS: Endograft deployment was technically successful in 44 patients (93.6%); clinical perioperative success was obtained in 46 patients (97.8%). In 12 patients (25.5%), a permanent reduction of the GFR was observed using postoperative TC-DTPA perfusion scintigraphy. By 99m TC-DTPA perfusion scintigraphy, a permanent reduction of GFR was observed postoperatively in 12 patients. A slight GFR reduction (<20%) was present in 7 (14.9%) patients, due to the planned occlusion of accessory renal arteries. A more significant GFR reduction (>20%) was present unexpectedly in 5 (10.6%) patients, in 3 of these a single kidney was involved, in 5 both with an increase of the serum creatinine level >20%. CONCLUSIONS: Suprarenal fixation of endografts in AAA treatment is a safe procedure with good early and midterm procedural results and a risk of GFR impairment (>20%) of 10.6%.
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Prospective, randomized study of external jugular vein patch versus polytetrafluoroethylene patch during carotid endarterectomy: perioperative and long-term results.
OBJECTIVES: The purpose of this study was to evaluate the relative risks and advantages of using external jugular vein (EJV) patch, compared with polytetrafluoroethylene (PTFE) patch, during carotid endarterectomy. The primary end point was the relevant neurologic complication rate (RNCR; fatal or disabling stroke) at any time during follow-up. Secondary end points included stroke-free survival, 30-day and long-term mortality, recurrent stenosis rate (> or =50%), occlusion, patch infection, aneurysm formation, and other local complications. METHODS: The study, a prospective randomized clinical trial carried out at a single center, was divided into two 3-year phases: December 1996 to March 1999, when patients were enrolled, and March 1999 to March 2002, which was the follow-up period. Inclusion criteria included an external jugular vein suitable for patching, defined as vein diameter 3 mm or larger and absence of collateral vessels noted on preoperative color duplex ultrasound scans. Patients were prospectively randomized 1:1 to receive either the EJV (n = 80; group A) or synthetic (n = 80; group B) patch. RESULTS: Carotid endarterectomy and patching was performed by one surgeon. At 30 months the RNCR-free rate, analyzed with the Kaplan-Meier method, was 98.7% for group A (1 ipsilateral lethal stroke) and 94.6% for group B (4 ipsilateral disabling strokes), and remained stable to 60 months. No statistical difference was observed with the log-rank test. Stroke-free survival rate was 100% for group A and 98.7% for group B at 1 year, 98.7% for group A and 93.6% for group B (1 ipsilateral minor stroke) at 30 months, and was unchanged at 60 months. Life table analysis demonstrated freedom from significant recurrent stenosis (> or =50%) of 97.5% for both groups at 6 months, 93.6% for group A and 92.2% for group B at 30 months, and 90.2% for group A and 86.7% for group B at 60 months. No statistical difference was observed with the log-rank test. In no patients was recurrent stenosis greater than 70%. No aneurysm formation was noted during follow-up. CONCLUSIONS: We can conclude, with the power limitation of the study, that carotid endarterectomy can be safely performed with either the EJV or PTFE patch. Advantages of the EJV for carotid angioplasty include no cost for material, low risk for graft infection, and preservation of the saphenous vein.
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Simultaneous surgical treatment of abdominal aortic aneurysm and carcinoma of the bladder.
OBJECTIVE: The purpose of this study was to evaluate the short-term and long-term results of simultaneous surgical treatment of coexisting abdominal aortic aneurysm and bladder carcinoma. METHODS: A prospective study was carried out to compare patients undergoing simultaneous surgical treatment of abdominal aneurysm and bladder carcinoma with control patients undergoing surgery for either one of the two diseases alone. From January 1995 to December 2000, 16 consecutive patients were seen with concomitant abdominal aortic aneurysm and bladder carcinoma at our institutional referral center. All patients underwent a standard operative protocol that included aneurysm graft replacement, radical cystoprostatectomy, and urinary reconstruction. Endovascular treatment of the aneurysm was considered in the last 2 years of the study. After each simultaneous treatment case, two control patients were selected according to the same type of vascular or urinary procedure, respectively, and pathologic staging. The analyzed endpoint was mortality, and confounder variables included common and disease-specific risk factors. Frequencies of vascular, urologic, and systemic complications were carefully considered with special attention to graft infection and tumor recurrence. RESULTS: Endovascular treatment was not performed for morphologic reasons. No perioperative mortality was observed. A trend toward inferior survival rates in simultaneously treated patients was observed in the early follow-up period, but survival analysis with log-rank test showed no statistical difference among the groups (P =.19). Cox proportional hazard model results proved no influence of the different group treatments on survival (P =.49) and no influence of age and risk factors, except for preoperative renal status (P =.015). The increased mortality rate of the simultaneous treatment group could be ascribed to the presence of preoperative moderate renal insufficiency in two study group patients. Long-term survival of treated patients is mainly dependent on cancer progression. Graft infection and other vascular complications were not observed. Systemic and urologic complications were similar in study and control groups. CONCLUSION: This study shows that the simultaneous surgical approach to coexisting abdominal aortic aneurysm and transitional cell carcinoma of the bladder represents a suitable choice of treatment in highly specialized centers, but patients with preoperative renal insufficiency should be carefully evaluated. Endovascular treatment represents an appealing alternative whenever indicated.
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